Columtjia  fflnitiersiitp 
mtf)eCitpofi^eto|9orfe 

CoUese  of  l^\)^iitiani  anb  ^urgeonsf 


Br.  Ctitoin  P.  Cragin 

1859-1918 


THE 


DISEASES   OF  WOMEN 


A  HANDBOOK  FOR  STUDENTS  AND 
PRACTITIONERS 


BY 

J.  BLAND    SUTTON,  F.  R.  C  S.  Enc, 

Surgeon  to  the  Chelsea  Hospital  for  Women;  Assistant  Surgeon, 
Middlesex  Hospital,  London  ; 

AND 

ARTHUR  E.  GILES,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S.  Edin., 

Assistant  Surgeon,  Chelsea  Hospital  for  Women,  London 


WITH  ri5   ILLUSTRATIONS 


rTITLADELPTITA 
W.    B.    SAUNDERS 

925  Walnut  Street 
1897 


LONDON:   RF.B^L^N  PUBLISHING  CO.,  Ltd.,  ii  Adam  St.,  Strand. 


Copyright,   1897, 
By\A/.     B.     SAUNDERS. 


PRESS  or 

WtSTCOTT   li   THOMSON     PHILAOA. 


ELECTHOTVPEO  OV 

W.    B     SAUNDERS     PHILAO* 


PREFACE. 


In  writing  this  book  it  has  been  our  earnest  desire  to 
relate  facts  and  describe  methods  belonging  to  the  science 
and  art  of  Gynaecology  in  a  way  that  may  be  useful  to 
students  for  examination  purposes,  and  which  will  also 
enable  them  to  practise  this  important  department  of  sur- 
gery with  advantage  to  their  patients  and  with  satisfaction 

to  themselves. 

J.  BLAND  SUTTON, 

ARTHUR  E.  GILES. 
London,  June,  1897. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofwomenhOOblan 


CONTENTS. 


CHAPTER  I. 


PAGB 

The  Anatomy  of  the  Reproductive  Organs  of  Women 17 

Ovaries,  17;  Parovarium,  18;  Fallopian  Tubes,  18;  Uterus,  19; 
Vagina,  20;  Vulva,  21;  Arteries,  23;  Veins,  25;  Lymphatics,  26; 
Nerves,  26;  Pelvic  Peritoneum,  26;  Mesometrium,  26. 

CHAPTER   II. 

Physiology  of  the  Reproductive  Organs  of  Women 30 

Menstruation,  30;  Anatomical  and  Physiological  Changes,  31  ;  Sig- 
nificance of  Menstruation,  36 ;  the  Menopause,  37. 

CHAPTER  III. 

Methods  of  Examination  of  the  Female  Pelvic  Organs    ....     38 
Abdominal    Examination,   38;     Vaginal    Examination,    39;     Bi- 
manual Examination,  40 ;  the  Uterine  Sound,  41  ;  the  Volsella,  44 ; 
the  Speculum,  45  ;   Examination  under  an  Anaesthetic,  48. 

CHAPTER    IV. 

Malformations  of  the  Reproductive  Organs  of  Women     ....     49 
Malformations  of   the  Vulva ;    Hermaphrodism   and   Pseudo-her- 
maphrudism,  49. 

CHAPTER  V. 

Malformations  of  the  Reproductive  Organs  of  Women  (Con- 
tinued)   59 

Malformations  of  the  Vagina,  59  ;  Absence  of  the  Vagina,  59 ; 
Atresia  of  the  Vagina,  59 ;  Stenosis  of  the  Vagina,  59 ;  Double 
Vagina,  60 ;  Malformations  of  the  Uterus,  61 ;  Absence  of  the 
Uterus,  61  ;  Rudimentary  Uterus,  61  ;  Infantile  Uterus,  6l  ;  Single- 
horned  Uterus,  62 ;  Double  Uterus,  63. 

5 

/' 


6  CONTENTS. 

CIIArrER  VI. 

rACB 

Retention  of  Menstrual  TRODUcrs  in  Atresia 68 

Atresia  of  the  Vagina,  68 ;  of  the  Os  Externum,  68 ;  kA  the  ( >^ 
Internum,  68;  affecting  One  Half  of  a  Double  Uterus  or  Vagina, 
68. 

CHAPTER  VII. 

Diseases  OF  the  Vulva  :  Age-changi;s  ;  Inflammations 77 

Age-changes,  77  ;  Injuries,  79  ;  Varix,  79 ;  Hafmatoma,  80 ;  Vul- 
vitis, 80 ;  CEdenia,  %i ;  Erysipelas,  83  ;  Gangrene,  84  ;  Abscess,  84. 

CHAPTER  VIII. 

Diseases  of  the  Vulva  (Continued)  :  Cutaneous  Diseases  ....     85 
Eczema,  85;  Herpes,  85;  Lupus,  86;  Syphilis,  86;    Elephanti- 
asis, 86 ;   Pruritus,  87 ;  Kraurosis,  88. 

CHAPTER  IX. 

Diseases  of  the  Vulva  (Continued):  Morbid  Conditions  of  the 

Clitoris,  Urethral  Orifice,  and  Perineum 91 

The  Hymen,  91 ;  Diseases  of  the  Clitoris,  93  ;  Urethral  Caruncle, 
93 ;   Ruptured  Perineum,  94. 

CHAPTER   X. 

Diseases  of  the  Vulva  (Continued)  :  Tumors  and  Cysts 97 

Li|K)mata,  97  ;  Myxomata,  97  ;  Sarcomata,  97  ;  .'Vngeiomata,  97  ; 
Papillomata,  97  ;  Epithelioma,  97  ;  Carcinoma,  99 ;  Mucous  Cysts, 
99 ;    Sebaceous  Cysts,  99 ;  Cysts  of  Bartholin's  Gland,  99. 

CHAPTER  XI. 
Diseases  of  the  Vagina  :  Age-changes;  Displacements  ;  Iniurii-:s  .  102 
Age-changes,  102;  Cystocele,  103;  Rectocele,  103;  Enterocele, 
107;  Injuries,  107;  Foreign  Bodies,  108;  Fistuloc,  109. 

CHAPTER  XII. 

D1SEASF.S  OF  THE  Vagina  (Continued)  :  Vaginal  Infection  and  the 

Vaginal  Secretions i" 

Normal  Vaginal  Secretion,  III;  Pathological  Vaginal  Secretion, 
114;  Varieties  of  Discharge  found  in  the  Vagina,  117. 


CONTENTS.  7 

CIIMTKR    XI I r. 

vscv. 

Diseases  of  the  Vagina  (Continued)  :  Inflammation,  Tumoks,  and 

Cysts ii8 

Vaginitis,  ii8;  Saicoma,  124;  Epilhelionia,  125;  Mucous  Cysts, 
125;  Gartncrian  Cysts,  125  ;  Peri-urelhral  Cysts,  126  ;  Echinococcus 
Colonics,  126. 

CHAPTER  XIV. 

Diseases  of  the  Uterus  :  Flexions  and  Displacements 127 

Age-changes,  127  ;  Uterine  Measurements,  127;  Anteflexion,  128; 
Retroflexion,  129;   Retroversion,  131. 

CHAPTER  XV. 

Diseases  of  the  Uterus  (Continued):    Displacements;    Hyper- 
trophy AND  Atrophy 136 

Prolapse  and  Procidentia,  136;  Hypertrophy  of  the  Supra-vaginal 
Portion,  141  ;  Hypertrophy  of  the  Vaginal  Portion,  144;  Atrophy 
of  the  Uterus,  146. 

CHAPTER  XVI. 

Pessaries 147 

Ring  Pessary,  148 ;  Hodge  Pessary,  148 ;  Vaginal  Stem  Pessary, 
150;  Contraindications  to  the  Use  of  Pessaries,  150;  Retained 
Pessary,  151. 

CHAPTER  XVII. 

Diseases  of  the  Uterus  (Continued)  :  Inversion  of  the  Uterus  .   153 

CHAPTER  XVIII. 

Diseases  of  the  Uterus  (Continued)  :  Injuries  ;  Diseases  result- 
ing from  Gestation 160 

Laceration  of  the  Cervix,  160;  Perforation  of  the  Uterus,  163; 
Superinvolution,  163;  Subinvolution,  164;  Retained  Products  of 
Conception,  165. 

CHAPTER  XIX. 

Diseases  of  the  Uterus   (Continued)  :    Diseases  of  the  Endo- 
metrium    i68 

Acute  Endometritis,  169;   Chronic  Endometritis,  172. 


CHAPTER  XX. 

PAGB 

Diseases  of  the  Uterus  (Continued):  The  Endometrium  (Con- 
tinued)     174 

Adenomatous  Disease  of  the  Cervix  (Erosion),  174;  Adenomatous 
Disease  of  the  Corporeal  Endometrium,  17S;  Tuberculosis,  179. 


CHAl'TEk  XXI. 

Diseases  ok  the  Uterus  (Continulii)  :  Mycmata 181 

^  Intramural  Myomata,  182;  Submucous  Myomala,  184;  .Subserous 
Myomata,  186;  Secondary  Changes,  186;  Impaction,  188;  Myomata 
and  Pregnancy,  189. 


CHAPTER  XXII. 

Diseases  of  the  Uterus  (Continued)  :  Clinical  Characters  axd 

Treatment  ok  Myomata 192 

Clinical  Characters,  192 ;  Diagnosis  of  Myomata  and  Pregnancy, 
193;  Normal  Pregnancy,  194;  Ilydramnion,  195;  Retroversion  of 
the  (}ravid  Uterus,  195;  Cornual  Pregnancy,  196;  Treatment  of 
Myomata,  198;  Polypi,  201. 


CHAPTER   XXni. 

Diseases  ok  the  Uterus  (Continued)  :  Sarcoma,  Adenoma,  and  Car- 
cinoma   202 

Sarcoma,  202;  Epithelioma,  206;  Adenoma.  207;  Carcinoma  of 
the  Cervix,  208;  Carcinoma  of  the  Body  of  the  Uterus,  212;  Re- 
tention-cysts, 213. 


CHAPTER    XXIV. 

Diseases  of  THE  Fallopian  Tubes 215 

Salpingitis,  215;  Pyosalpinx,  217  ;  Hydrosalpinx,  218 ;  Ilamato- 
salpinx,  219;  Tubercular  Salpingitis,  220;  Tumors  of  the  Fallopian 
Tube,  222. 


CHAPTER  XXV. 

Diseased  of  the  Fallopian  Tubes  (Continued)  :  Diagnosis   and 

Treatment  of  Salpingitis 224 

Acute  Salpingitis,  224 ;  Chronic  Salpingitis,  225. 


CONTENTS.  9 

CHAPTER  XXVI. 

PAGE 

Diseases  of  the  Fallopian  Tubes  (Continued)  :  Tubal  Gestation  .  229 
Tubal  Changes,  230 ;  the  Tubal  Mole,  231  ;  Tubal  Abortion,  232  ; 
Rupture  of  the  Gestation-sac,  234 ;  Tubo-uterine  Gestation,  239. 

CHAPTER  XXVn. 

Diseases  of  the  Fallopian  Tubes  (Continued)  :  Tubal  Gestation 

(Continued) 241 

Diagnosis,  241  ;  Treatment,  245. 

CHAPTER  XXVni. 

Diseases  of  the  Ovaries 250 

Age-changes,  250 ;  Malformations,  251  ;  Displacements,  251 ; 
Corpus  Luteum,  255;  Apoplexy  of  the  Ovary,  256;  Oophoritis, 
257;  Cirrhosis  of  the  Ovaries,  259;  Ovarian  Neuralgia,  259. 

CHAPTER   XXIX. 

Diseases  of  the  Ovaries  (Continited)  :  Tumors  and  Cysts  ....  261 
Fibromata,  261;    Myomata,    261;    Sarcomata,   262;    Carcinoma, 
263  ;  Simple  Cysts,  263  ;  Adenomata,  265 ;  Dermoids,  265  ;  Papil- 
lomatous Cysts,  269  ;   Parovarian  Cysts,  270  ;  Gartnerian  Cysts,  271. 

CHAPTER  XXX. 

Diseases  of  the  Ovaries  (Continued)  :    Secondary  Changes  in 

Ovarian  Tumors 273 

Septic  Infection,  273  ;  Axial  Rotation,  275  ;  Rupture,  276;  Symp- 
toms and  Diagnosis  of  Ovarian  Tumors,  277. 

CHAPTER   XXXI. 

Diseases  of  the  Ovaries  (Continued)  :  Differential  Diagnosis 

and  Treatment  of  Ovarian  Tumors 2S1 

Phantom  Tumor,  282;  Pregnancy,  282;  Ascites,  283;  Distended 
Bladder,  283;  Kidney,  Spleen,  Liver,  284;  Ovarian  Tumors  and 
Pregnancy,  2S5 ;  Treatment  of  Ovarian  Tumors,  286. 

CHAPTER  XXXII. 
Diseases  of  the  Pelvic  Peritoneum  and  Cellular  Tissue   ....  2S8 
Septic  Infection,  288;  Epithelial  Infection,  289  ;  Hydroperitoneum, 
290  J  Pelvic  Cellulitis,  292;   Pelvic  Abscess,  293. 


lO  CONJENJS. 

CHAPTER  XXXIII. 

rxcB 

Diseases  ok  the  Pelvic  Peritoneum  and  Celli'lar  Tissue  (Con- 
tinued) :  Tlmors 296 

Lipomata,  296;  Myomata,  296;  Sarcomata,  297;  Echinococcus 
Colonies  of  the  Pelvis,  297. 

CHAITEK    XXXIV. 

Disorders  of  Menstruation 301 

Amenorrhcca,  301  ;  CryptomenorrlnLa,  303 ;  Menorrhagia  and 
Metrorrhagia,  304;  Dysmenorrhcea,  306;  Membranous  Dysmenor- 
rhoea,  310. 

CHAPTER  XXXV. 

Vaginismus  and  Dyspareunia;  Sterility 312 

Vaginismus,  312;  Dyspareunia,  313;  Sterility,  314. 

CHAPTER  XXXVI. 

Diagnosis 318 

Family  History  and  Previous  Health,  318;  Menstruation,  319; 
Confinements  and  Miscarriages,  319 ;  Present  Illness,  320;  Present 
Symptoms,  321  ;  Rectal  and  Vesical  Symptoms,  322 ;  General 
Symptoms,  323. 

CHAPTER  XXXVH. 

Diagnosis  (Continued)  :  The  Physical  Examination 325 

General  Health  and  Appearance,  325  ;  Heart,  Lungs,  etc.,  325  ; 
Abdominal  Examination,  325  ;  Vaginal  Examination,  328. 

CHAPTER  XXXVIII. 

GYNitCOLOGICAL   OPERATIONS 2>ii 

General  Considerations,  333 ;  Operations  during  Menstruation, 
335;  Preparation  of  the  Patient,  335;  the  Crutch,  336;  the 
Sterilizer,  339. 

CHAPTER  XXXIX. 

Vaginal  Operations:  Operations  on  the  Perineum,  Vulva,  and 

Vagina     34' 

Perineorrhaphy,  341 ;  Removal  of  Urethral  Caruncle,  347 ;  Re- 
moval of  the  Clitoris,  348 ;  Bartholinian  Cysts,  349 ;  Coljxjrrhaphy, 
350- 


CONTENTS.  1 1 

CHAPTER  XL. 

HAGS 

Vaginal  Operations  (Continued)  :  Vaginal  Fistula;  Atresia  ok 

THE  Genital  Canal 352 

Vesi CO- vaginal  Fistula,  352 ;  Uretero-vaginal  Fistula,  354  ;  Ulcro- 
vesical  Fistula,  355  ;  Recto-vaginal  Fistula,  355 ;  Colpocleisis,  355  ; 
Imperforate  Hymen,  355  ;  Cicatricial  Union  of  the  Labia,  356 ; 
Occlusion  of  the  Vagina,  357 ;  Atresia  of  the  Cervix,  358. 

CHAPTER  XLI. 

Vaginal  Operations  (Continued)  :  Operations  on  the  Uterus  .    .  359 
Dilatation  of  the  Cervix,  359;  Curetting,  360;  Vaginal   Myomec- 
tomy, 363. 

CHAPTER  XLH. 

Vaginal  Operations  (Continued)  :    Operations   on   the  Uterus 

(Continued) 368 

Trachelorrhaphy,  368  ;  Amputation  of  the  Cervix,  370 ;  Amputa- 
tion of  the  Hypertrophied  Cervix,  372  ;  Vaginal  Hysterectomy,  373 ; 
Anterior  Colpotomy,  376. 

CHAPTER   XLIIL 

Abdominal  Operations  :  General  Considerations 379 

Coeliotomy,  379 ;  Preparation  of  the  Patient,  379 ;  Instruments, 
380 ;  Suture  and  Ligature  Material,  380;  Sponges,  381  ;  the  Table, 
382 ;  Anaesthesia,  3S2 ;  Abdominal  Incision,  382 ;  Closure  of  the 
Wound,  383 ;  Dressing,  384  ;  In'igation,  384  ;  Drainage,  384. 

CHAPTER  XLIV. 

Abdominal  Operations  (Continued)  :  Ovariotomy  and  Oophorec- 
tomy   387 

Ovariotomy,  387  ;  Incomplete  Ovariotomy,  394  ;  Anomalous  Ovari- 
otomy, 394;  Repeated  Ovariotomy,  395  ;  Oophorectomy,  395. 

CHAPTER  XLV. 

Abdominal  Operations  (Continued)  :  Ovariotomy  (Continued)    .  399 
After-treatment,  399 ;  Risks  of  Ovariotomy,  401  :  Injury  to  \'is- 
cera,  402  ;   Foreign   Bodies   Left  in  the  Abdomen,  404;   Sequelre  of 
Ovariotomy,  405  ;  Remote   Effects  of  Ovariotomy  on  Primary  and 
Secondary  Sexual  Characters,  407. 


12  CO.V'/L.Vy^. 

CHAPTER  XLVI. 

PACE 

Abdominal    Oi-erations    (Continued)  :    Operations    for    Tibal 

i'regnancy 408 

At  the   Time  of  Priman-  Rupture,  408;    Subsequent  to  Primary 
Rupture,  409  ;  Mesometric  Rupture,  409  ;  After  the  Fifth  Month,  409. 

CHAPTER  XLVH. 
Abdominal  Operations  (Continued)  :  Operations  on  the  Uterus  .  411 
Supra-vaginal  Hysterectomy,  411;  Pan-hysterectomy,  414;  Myo- 
mectomy, 415;    Ccesarean   Section,  416;    Porro's  Operation,    418: 
Hysteropexy,  419;  Shortening  the  Round  Ligaments,  421. 


LIST  OF  ILLUSTRATIONS. 


FIGURE  PAGE 

1.  Sagittal  section  of  the  female  pelvis 19 

2.  The  vulva  of  an  adult 22 

3.  Diagram  of  the  uterine  and  ovarian  arteries 23 

4.  Diagram  of  the  hypogastric  stem 24 

5.  Diagram  of  ovulation 32 

6.  Stages  in  the  formation  of  a  corpus  luteum 34 

7.  The  uterine  sound •••....    42 

8.  Volsellce 45 

9.  Fergusson's  speculum 4° 

10.  The  duck-bill  speculum 46 

11.  Generative  organs  of  the  embr)o 5^ 

12.  Generative  organs  of  the  male 52 

13.  Generative  organs  of  the  female 54 

14.  The  external  organs  of  a  bypospadiac  male 5^ 

15.  Uterus  in  a  boy 57 

16.  Exstrophy  of  the  bladder  in  a  girl 5^ 

17.  Rudimentary  uterus 60 

18.  Conical  cer\-ix 61 

19.  Normal  nulliparous  cei"vix      61 

20.  Multiparous  cervix      61 

21.  Unicom  uterus 63 

22.  Uterus  bicomis ...    64 

23.  Uterus  didelphys     .    , 65 

24.  Diagram  illustrating  the  effects  of  atresia 69 

25.  Diagram  illustrating  the  effects  of  atresia 7° 

26.  Vulva  of  a  girl 77 

27.  The  Hottentot  apron 7^ 

28.  Variations  in  the  shape  of  the  hymeneal  aperture 91 

29.  The  vestibular  bulb  and  Bartholin's  glands 100 

30.  Cystocele  and  rectocele 104 

31.  Vaginal  secretion  containing  the  vagina  bacillus 112 

32.  Cultivation  of  the  vagina  bacillus 1 13 

33.  Gonococci II5 

34.  The  uterus  in  sagittal  section 127 

35.  Diagram  illustrating  flexions  of  the  uterus 130 

13 


14  LIST  OF  ILLUSTRATIONS. 

FIGl'KB  FACR 

36.  Prolapse  of  the  ulcrus 1 38 

37.  Hypertrophy  of  the  supra- vaj;iiial  Cervix 142 

3S.  Two  dia<jranis  contrasting  liypcrlrophy  of  the  vaginal  and  of  the 

supra-vaginal  portion  of  the  cervix 143 

39.  Diagram  to  show  the  three  zones  of  the  cervix 144 

40.  A  prolapsed  uterus  in  sagittal  section 145 

41.  A  ring  (rubber)  pessary 14S 

42.  Hodge's  pessary 149 

43.  Glycerin  pessary 149 

44.  Vaginal  stem-pessary 15' 

45.  Inversion  of  the  uterus 154 

46.  An  inverted  uterus  (opened) 155 

47.  Partial  inversion  of  the  uterus 156 

48.  Uterine  repositor 158 

49.  Bilateral  laceration  of  the  cervix 160 

50.  Four  diagrams  of  cervical  laceration 162 

51.  Retained  fragment  of  placenta 165 

52.  Microscopical  appearance  of  recent  jilacental  tissue 166 

53.  Microscopical  appearance  of  retained  placental  tissue 166 

54.  Horizontal  section  of  the  body  of  the  uterus 168 

55.  Adenomatous  disease  of  the  cervix 174 

56.  Adenomatous  disease  of  the  cervix 174 

57.  Microscopic  characters  of  adenomatous  disease  of  the  uterus    .    .    .175 

58.  Microscopic  characters  of  adenomatous  disease  of  the  uterus   .    .    .176 

59.  Uterus,  showing  myomata 182 

60.  Intra-cervical  myoma 183 

61.  Very  vascular  myoma 184 

62.  Uterus  with  an  extruded  myoma 185 

63.  Impacted  uterine  myoma 189 

64.  Gravid  myomatous  uterus' .    .  190 

65.  Mucous  polypus 201 

66.  Deciduoma  of  the  uterus 203 

67.  Group  of  decidual  cells      204 

68.  Sarcoma  of  the  cervix  uteri 205 

69.  Microscopic  characters  of  uterine  sarcoma 206 

70.  Carcinoma  of  the  cervix  uteri 207 

71.  Microscopic  characters  of  carcinoma 208 

72.  Cancer  of  the  cervix  uteri 209 

73.  Cancer  of  the  cervix  uteri  implicating  the  ureter 210 

74.  Microscopic  characters  of  cancer  of  the  uterus 213 

75.  Fallopian  tube  with  occluded  ostium 216 

76.  Tubo-ovarian  abscess 218 

77.  Hydrosalpinx 219 

78.  Tubercular  salpingitis 221 


LIST  OF  ILLUSTRATIONS.  15 

FIGURE  PAGE 

79.  Tubercular  salpingitis ; 226 

80.  Gravid  Fallopian  tube  with  occluded  ostium 231 

81.  Tubal  mole 232 

82.  Tube  after  tubal  abortion 233 

83.  Uterus  with  decidua  in  situ 237 

84.  Pelvic  organs  of  a  fcetus 252 

85.  Hernia  of  the  ovary 253 

86.  Fibroma  of  the  ovary 262 

87.  Ovarian  dermoid 264 

88.  Ovarian  teeth  and  bone 265 

89.  Microscopic  characters  of  skin  from  a  dermoid 266 

90.  Ovarian  dermoid  in  a  girl  of  seven  years 267 

91.  Papillomatous  cyst 269 

92.  Parovarian  cyst 270 

93.  Ovarian  fibroma  obstructing  labor 285 

94.  Diagram  of  local  abdominal  swellings 326 

95.  Diagram  of  local  abdominal  swellings 327 

96.  Crutch  for  gynaecological  operations 337 

97.  Patient  in  the  lithotomy  position 338 

98.  A  sterilizer 339 

99.  Perineorrhaphy  :  first  stage 342 

100.  Perineorrhaphy  :  second  stage 343 

loi.  Perineorrhaphy:  third  stage 344 

102.  Operation  for  vesico-vaginal  fistula  :  mode  of  passing  the  sutures    .  354 

103.  Fenton's  dilators 361 

104.  Curettes 361 

105..  Trachelorrhaphy  :  first  stage 369 

106.  Trachelorrhaphy  :  second  stage 370 

107.  Trachelorrhaphy:  third  stage 371 

108.  The  first  stage  of  vaginal  hysterectomy 374 

109.  Ovariotomy-trocar , 387 

no.  Ovariotomy-trocar 388 

111.  Pedicle-needle 389 

112.  Sponge-holder 3S9 

113.  Diagram  to  illustrate  the  position  of  the  uterine  arteries  during  ab- 

dominal hysterectomy 412 

114.  Diagram  to  illustrate  the  position  of  the  uterine  arteries  during  ab- 

dominal hysterectomy 413 

115.  Method  of  suture  in  hysteropexy 420 


DISEASES   OF  WOMEN. 


CHAPTER    I. 

THE  ANATOMY  OF  THE  REPRODUCTIVE  ORGANS  OF 
WOMEN. 

The  essential  organs  of  reproduction  in  a  woman  are 
two  glandular  bodies  known  as  the  ovaries,  in  which  ova 
(eggs)  are  formed.  The  remaining  organs,  more  or  less 
subservient  to  the  ovaries,  are  the  Fallopian  tubes,  which 
conduct  the  ova  to  the  Uterus,  in  which,  when  fertilized, 
they  are  retained  through  the  embryonic  stages.  The  ute- 
rus communicates  with  the  exterior  by  the  vagina,  a 
mucous  tube  which  receives  the  intromittent  organ  (penis) 
for  the  purpose  of  impregnation.  The  orifice  of  the  vagina 
is  limited  in  the  virgin  by  the  hymen.  The  parts  exter- 
nal to  the  hymen  are  termed  the  vtllva,  and  consist  mainly 
of  modified  skin  arranged  in  folds.  The  folds  of  the  vulva 
contain  the  peripheral  end-organs  concerned  in  sexual  sen- 
sation, and  some  glandular  structures  the  secretion  from 
which  facilitates  the  introduction  of  the  virile  organ.  Each 
part  requires  separate  notice. 

The  Ovaries. — Each  ovary  is  an  olive-shaped  body, 
somewhat  compressed  in  its  long  axis,  projecting  from  the 
posterior  fold  of  the  mesometrium.  It  lies  near  the  brim 
of  the  true  pelvis,  surrounded  on  two-thirds  of  its  circum- 
ference by  the  ampulla  of  the  corresponding  Fallopian  tube. 
Each  ovary  is  connected  with  the  cornu  of  the  uterus  by 
a  band   of   muscular  tissue  named  the  ovarian   ligament. 

2  17 


iS  DJSEASKH    OJ'    nOMKN. 

Morphologically  the  ovary  consists  of  two  parts  :  that  which 
forms  its  free  surface  is  the  egg-beariii<^r  j)art,  and  is  called 
the  oophoron ;  the  part  in  relation  with  the  mesonietrium 
is  the  paroophoron,  and  represents  the  degenerated  re- 
mains of  the  t;landular  part  of  the  mesonephros.  It  con- 
tains no  follicles,  but  is  rich  in  blood-vessels. 

The  Parovarium, — This  structure  is  easily  seen,  when 
the  mesosalpinx  is  stretched  and  held  between  the  eye  and 
the  light,  as  a  scries  of  tubules  radiating  from  the  ovary  to 
join  a  longitudinal  tubule  situated  at  a  right  angle  to  them. 
Although  the  tubules  converge  as  they  enter  the  paro- 
ophoron, nevertheless  they  remain  distinct.  Each  tubule 
ends  blindly,  and  is  lined  with  epithelium.  When  present 
in  its  typical  condition,  the  parovarium  consists  of  three 
parts :  an  outer  scries  of  tubules,  free  at  one  extremity, 
known  as  Kobelt's  tubes ;  an  inner  set,  termed  the  vertical 
tubules  (the  parovarium  contains,  as  a  rule,  twelve  tubules ; 
sometimes  as  many  as  seventeen  may  be  counted,  and  in 
other  specimens  as  few  as  five) ;  lastly,  running  at  right 
angles  to  the  vertical  tubules,  there  is  a  larger  tube  which 
may  occasionally  be  traced  downward  to  the  vagina.  This 
is  Gartner's  duct ;  it  corresponds  to  the  vas  deferens  in 
the  male. 

The  Fallopian  Tubes. — These  tubes  conduct  ova  from 
the  ovaries  to  the  uterus.  Each  tube  is  continuous  with  the 
superior  angle  of  the  uterus,  posterior  to  the  point  of  attach- 
ment of  the  round  ligament.  When  straightened  a  Fal- 
lopian tube  measures  on  an  average  4  inches  (10  cm.);  it 
opens  by  a  peculiarly  fringed  opening — the  abdominal  ostium 
— into  the  ccelom  (peritoneal  cavity).  The  inner  third  or 
isthmus  of  the  tube  is  tortuou.s  and  narrower  than  the  outer 
two-thirds,  termed  the  ampulla.  Each  Fallopian  tube  lies 
in  the  free  border  of  that  portion  of  the  mesometrium  known 
as  the  mesosalpinx.  The  ampulla  of  the  tube  embraces  the 
ovary  (Fig.  i).  When  an  ovum  escapes  from  the  ovary  it 
falls  among  the  tubal  fimbriae  and  gains  the  ostium  of  the 


ANATOMY  OF  RErKODUCTIVE    ORGANS. 


19 


tube ;  it  is  then  propelled  by  muscular  contractions  along 
the  tube  to  the  uterus.  The  outer  end  of  the  Fallopian 
tube  is  connected  by  a  modified  fimbria,  termed  the  tubo- 


FiG.  I. — Sagittal  section  of  the  female  pelvis  (Dickinson). 


ovarian   ligament,  with   the  end  of  the  ovary  opposite  to 
that  which  receives   the  ovarian  ligament. 

The  Uterus  (PVomd).  —  A  pyriform  body,  consisting 
mainly  of  involuntary  muscular  fibres,  and  containing  a 
central  fissure-like  cavity  lined  with  mucous  membrane. 
Superiorly  this  cavity  is  continuous  with  the  lumen  of 
each  Fallopian  tube ;  inferiorly  it  communicates  with  the 
cervical  canal  by  an  orifice  known  as  the  internal  os.     The 


20  DISEASES   OJ-    WOMEN. 

uterus  is  divided  into  three  parts,  of  which  two — the  body 
and  fundus — project  freely  into  the  pelvic  cavity  and  re- 
ceive an  investment  of  peritoneum.  The  fundus  is  that 
portion  lyin<^  above  the  level  of  the  internal  orifices  of 
the  Fallopian  tubes ;  the  lower  limit  of  the  body  is  the 
internal  os.  The  remaining  segment  of  the  uterus  is  the 
neck  or  cervix :  it  invaginates  the  mucous  membrane  of 
the  vagina,  forming  a  conical  protrusion  in  this  tube.  The 
cervix  is  traversed  by  a  central  passage  known  as  the  cer- 
vical canal,  communicating  with  the  uterine  cavity  above  at 
the  internal  os,  whilst  its  lower  opening  is  know'n  as  the 
external  os,  or  commonly  the  "  os  uteri." 

A  fibro-muscular  process — the  round  ligament — projects 
from  each  angle  of  the  uterus  anterior  to  the  Fallopian 
tube,  and  after  traversing  the  inguinal  canal  is  gradually 
lost  in  the  tissue  of  the  labium  majus. 

The  Vagina. — This  is  a  dilatable  mucous  canal  extend- 
ing from  the  vulva  to  the  cervix  uteri.  The  bladder  and 
urethra  lie  on  its  anterior  wall ;  posteriorly  it  rests  on  the 
lower  segment  of  the  rectum.  It  receives  the  penis  during 
copulation.  When  distended  it  is  circular  in  section,  when 
empty  its  cavity  is  represented  by  a  transverse  fissure,  the 
anterior  and  posterior  walls  lying  in  apposition.  The  direc- 
tion of  the  vagina  is  represented  in  Fig.  i,  from  which  it 
will  be  seen  that  the  posterior  is  longer  than  the  anterior 
wall  by  nearly  an  inch  (2.5  cm.).  The  average  measurements 
are  2\  in,  (6  cm.)  for  the  anterior  and  3|-  in.  (8  cm.)  for  the 
posterior  wall.  The  recess  formed  by  the  reflection  of  the 
mucous  membrane  over  the  anterior  aspect  of  the  cervix 
uteri  is  known  as  the  anterior  vaginal  fornix,  the  recess 
behind  the  cervix  is  the  posterior  vaginal  fornix ;  it  is  a 
deeper  cul-de-sac  than  the  anterior.  The  mucous  mem- 
brane of  the  vagina  is  thrown  into  numerous  transverse 
folds  :  on  the  anterior  wall  a  vertical  fold  begins  behind  the 
urinary  meatus  and  extends  upwards  for  nearly  i  in.  (2.5 
cm.).     When  veiy  distinct  it  is  called  the  anterior  column 


ANATOMY  OF  REPRODUCTIVE    ORGANS.  21 

of  the  vagina.  A  similar  fold  present  on  the  opposite 
wall  is  named  the  posterior  vaginal  column.  The  outer 
orifice  of  the  vagina  is  bounded  on  each  side  by  the  leva- 
tor ani  muscle.  The  orifice  can  be  greatly  narrowed  by 
the  contraction  of  these  muscles. 

The  Vulva. — This  term  is  applied  collectively  to  those 
structures  often  called  the  external  genitals,  and  includes: 
I.  The  Mons  Veneris.  2.  The  Labia  majora  and  minora. 
3.  The  Clitoris.     4.  The  Hymen. 

The  Mons  Veneris. — This  is  an  eminence  formed  by  a 
collection  of  subcutaneous  fat  situated  in  front  of  the  sym- 
physis pubis.  The  skin  covering  it  is  in  the  adult  con- 
spicuously furnished  with  hair,  usually  of  the  same  color 
as  that  on  the  head  of  the  individual. 

TJie  Labia  Majora. — These  are  two  large  parallel  folds 
of  skin  extending  from  the  mons  Veneris  to  near  the  anus. 
The  fissure  between  the  labia — the  rima  pudendi — is  defi- 
nitely limited  posteriorly  by  a  thin  cutaneous  fold  known 
as  the  fourchette,  which  forms  a  horizontal  commissure 
between  the  labia  and  marks  the  anterior  limit  of  the  peri- 
neum. The  outer  surfaces  of  the  labia  are  beset  with  hairs 
and  glands  and  are  more  deeply  pigmented  than  the  skin 
generally.  The  opposed  surfaces  of  the  labia  are  pink, 
and  possess  rudimentary  hairs,  but  very  large  sebaceous 
glands.  The  subcutaneous  tissue  of  the  labia  contains 
dartos,  fat,  and,  deeper  still,  erectile  tissue  in  the  form  of 
two  oval  bodies  known  as  the  bulbi  vestibuli  (Fig.  29). 

The  Labia  Minora  {Nymplice). — Two  thin,  pink,  cutane- 
ous folds,  which  though  hairless  are  rich  in  large  sebaceous 
glands.  The  nymphse  lie  parallel  with  the  greater  labia : 
above  they  become  confluent  at  the  fra^num  of  the  clitoris : 
below  they  are  gradually  lost  on  the  inner  surfaces  of  the 
labia  majora. 

TJie  Clitoris. — This  is  a  rudimentary  penis,  but  differs 
from  it  in  not  being  traversed  by  the  urethra.  It  arises  by 
a  crus  from  each  pubic  arch,  near  the  symphysis.    The  con- 


22  D/SEASKS    Of   JrOMEX. 

fluent  crura  form  the  body  of  the  clitoris,  which  is  held  by 
a  suspensory  ligament  to  the  front  of  the  symphysis.  The 
extremity  ends  in  a  small  glans-like  body  formed  of  erec- 
tile tissue,  and  peeps  from  a  cutaneous  prepuce-like  fold 
which  inferiorly  forms  a  median  bridle  or  fraenum. 

The  Hymen. — A  septum  of  mucous  membrane  at  the 
junction  of  the  vagina  and  vulva.  When  the  labia  are 
widely  separated,  as  in  Fig.  2,  the  hymen  has  the  appear- 


.^^A^ 


■  Mons  Veneris. 

■  Greater  labium. 
•  Clitoris. 

-  Glatis  clitoridis. 


»_V i ^4:^ Urethra. 

\     V ^^/ " Lesser  labium. 


-Hymen. 

-Fourchette. 
-Perineum. 

-Anus. 


Fig.  2. — The  vulva  of  an  adult,  with  the  labia  separ.ited  to  show  the  various  parts  (after 

(Sappey). 

ance  of  a  perforated  diaphragm.  When  the  parts  lie  in 
their  natural  positions  the  hymen  forms  two  folds  and  the 
perforation  becomes  a  fissure;  the  edges  of  the  fissure  are 
then  the  most  prominent  part  of  the  h>'men  and  lie  paral- 
lel with,  but  deeper  in  the  vulvar  cleft  than,  the  nymphnj. 


ANATOMY  OF  REPRODUCTIVE    ORGANS. 


23 


When  the  labia  are  separated  certain  spaces  are  exposed 
which  receive  special  names.  Of  these  the  most  conspicu- 
ous is  the  vestibule,  an  area  limited  in  front  by  the  glans  of 
the  clitoris,  behind  by  the  margin  of  the  vulvar  orifice ; 
laterally  it  is  limited  by  the  converging  borders  of  the 
nymphae.  The  urethra  terminates  in  this  space.  At  the 
posterior  part  of  the  vulvar  cleft  there  is  a  well-marked 
depression  limited  by  the  hymen  and  fourchette,  known  as 
the  fossa  navicularis. 

The  opposed  surfaces  of  the  labia,  great  and  small,  are 
kept  moist  with  the  secretion  furnished  by  the  glands  lodged 
in  their  cutaneous  investment.  In  addition  there  are  two 
special  structures  known  as  the  glands  of  Bartholin,  which 
measure  i  cm.  in  width,  lodged  one  on  each  side  near  the 
outer  aperture  of  the  vagina.  The  orifice  of  each  duct 
opens  in  the  recess  between  the  corresponding  labium  mi- 
nus and  the  fold  of  the  hymen  (Fig.  29). 


OVARIAN  AR 


ROUND  LIGAMENT 


UTERINE  ART 


Fig.  3. — Diagram  showing  the  uterine  and  ovarian  arteries. 


The  Arteries. —  i.  The  Ovarian  Arterj.—Thxs  vessel 
arises  on  each  side  from  the  abdominal  aorta  below  the 
renal  arteries,  and  runs  downward  in  the  subserous  tissue 


24 


DISEASES   or   WOMEN. 


to  pass  between  the  layers  of  llie  niesomctrium  at  the  brim 
of  the  i)elvis ;  it  tlieii  makes  its  way  to  the  side  of  tlie 
uterus  near  the  fundus  to  inoscuhite  with  the  uterine  artery. 
In  its  mesometric  course  branches  are  distributed  to  tlie 
ovary,  Fallopian  tube,  fundus  of  the  uterus,  and  the  meso- 
metric connective  tissue  (Fig.  3) ;  an  arterial  twig  also  issues 
from  it  to  anastomose  with  a  small  vessel  derived  from  the 
deep  epigastric  arter)-,  which  is  conducted  along  the  round 
ligament  of  the  uterus. 

2.    The   Uterine  Artery. — In  a  large  proportion  of  cases 
this  artery  comes  from  the  h}'pogastric  trunk,  a  branch  of 

Common  iliac. 


Hypogastric  stem. 
Superior  vesical. 
Inferior  vesical. 

Uterine. 

AfiJdle  hamorrhoidal. 

Obturator. 

Internal  pudic. 


Sciatic. 


Gluteal. 


Fig.  4. — Diagram  to  show  the  uterine  artery  arising  from  the  hypogastric  stem  (Parsons 

and  Keith). 


the  anterior  division  of  the  internal  iliac,  which  breaks  up 
into  superior  vesical,  inferior  vesical,  and  uterine  branches 
(Fig.  4).  In  other  cases  the  uterine  artery  arises  as  a  sepa- 
rate branch  from  the  anterior  division  of  the  internal  iliac. 
It  runs  under  the  peh'ic  peritoneum  toward  the  cer\i.\  :  on 


ANAl'OMY  OF  RErRODUCTIVR    ORGANS.  2$ 

entering  the  mesometrium  it  turns  upward  and  pursues  a 
tortuous  course  on  the  side  of  the  uterus  nearer  the  pos- 
terior than  the  anterior  surface,  and  on  approaching  the 
fundus  inoscuhites  with  the  ovarian  artery.  In  its  course 
along  the  uterus  it  gives  many  branches  which  pass  across 
the  anterior  and  posterior  wall  of  the  organ  to  anastomose 
with  corresponding  twigs  from  the  opposite  artery. 

3.  77u'  Vaginal  Ai-fcrics. — There  are  two  or  three  vagi- 
nal arteries  which  arise  from  the  anterior  division  of  each 
internal  iliac  artery,  or  they  may  be  derived  from  the  uter- 
ine or  middle  ha^morrhoidal  arteries.  They  traverse  the 
pelvic  connective  tissue  and  ramify  on  the  walls  of  the 
vagina,  anastomosing  with  the  vessels  of  the  opposite 
side. 

4.  The  Vulvar  Arteries. — The  greater  and  lesser  labia  are 
supplied  by  branches  from  the  superficial  and  deep  external 
pudics  and  the  superficial  and  transverse  perineal  branches 
of  the  internal  pudic.  The  clitoris  derives  its  blood-supply 
from  the  terminal  branches  of  the  internal  pudic  arter}', 
which  arises  from  the  anterior  division  of  the  internal  iliac. 
This  vessel  also  gives  branches  to  the  skin  and  the  deep 
tissues  of  the  labia,  including  the  bulbi  vestibuli. 

The  Veins. —  i.  Ovarian  Veins. — These  are  situated 
mainly  in  the  mesosalpinx,  where  they  form  the  pampini- 
form plexus.  Near  the  outer  end  of  the  mesosalpinx  the 
veins  coalesce  and  form  a  single  vessel — the  ovarian  vein — 
which  joins  on  the  right  side  the  inferior  vena  cava,  and  on 
the  left  side  the  renal  vein. 

2.  The  Uteritie  Veins. — These  form  a  large  plexus  in  each 
mesometrium  ;  the  individual  branches  are  sometimes  very 
large.  From  this  plexus  a  single  trunk  issues  to  join  the 
internal  iliac  vein. 

3.  The  Vaginal  J^eins. — These  form  a  plexus  around  the 
vagina  from  which  definite  branches  issue  and  accompany 
the  arteries. 

4.  The    Vulvar   J^eins. — These  also  accomjian)'  the  cor- 


26  DISEASES   OE   WOMEN. 

responding  arteries.  The  superficial  external  pudic  vein 
terminates  in  the  great  saphena  vein.  The  internal  pudic 
ends  in  the  internal  iliac  vein.  The  veins  from  the  bulbi 
vestibuli  communicate  with  the  vaginal,  pudic,  and  obtura- 
tor veins. 

The  Ivymphatics. — The  lymphatics  follow  the  course 
of  the  veins.  Thus  the  lymphatics  from  the  ovaries, 
the  Fallopian  tubes,  and  fundus  of  the  uterus  accompany 
the  ovarian  veins  and  terminate  in  the  lumbar  lymph  glands. 
The  lymphatics  of  the  round  ligament  of  the  uterus  join 
the  inguinal  glands ;  whilst  those  of  the  lower  segment  of 
the  body  of  the  uterus  and  its  cervix  open  into  the  glands 
lying  alongside  the  iliac  vessels.  The  vaginal  lymphatics 
join  the  pelvic  glands.  The  vulvar  lymphatics  open  into 
the  inguinal  glands,  but  those  from  the  clitoris  accompany 
the  internal  pudic  arteries  to  the  pelvic  glands. 

The  Nerves. — The  nerves  of  the  ovaries.  Fallopian 
tubes,  and  uterus  are  derived  from  the  .sympathetic  .system, 
and  are  conducted  to  them  along  the  vessels :  branches 
from  the  renal  plexus  are  conveyed  to  the  ovaries  and  tubes 
by  the  ovarian  arteries,  whilst  the  hypogastric  plexus,  inter- 
mingled with  twigs  from  the  third  and  fourth  sacral  nerves, 
supplies  the  uterus  and  vagina. 

The  vulvar  structures  are  supplied  by  the  ilio-inguinal 
nerve  and  the  long  pudendal  branch  of  the  small  sciatic 
nerve.  A  branch  of  the  genito-crural  accompanies  the 
round  ligament  of  the  uterus  into  the  labium  majus.  The 
clitoris  is  supplied  by  the  internal  pudic :  this  is  a  compara- 
tively large  ner\'e,  and  its  terminal  twigs  end  in  tactile  cor- 
puscles. This  nerve  by  its  superficial  perineal  branches  also 
supplies  the  labia. 

The  Pelvic  Peritoneum. — The  pelvic  peritoneum  in 
women  has  a  complex  disposition  which  it  is  necessar}'  to 
thoroughly  appreciate  in  order  to  comprehend  the  various 
morbid  conditions  to  which  the  pelvic  organs  are  liable. 

The  peritoneum  as  it  descends  from  the  posterior  wall  of 


ANATOMY  OF  REPRODUCTIVE    ORGANS.  2/ 

the  abdomen  enters  the  cavity  of  tlie  true  pelvis  and  covers 
the  anterior  face  of  the  sacrum,  the  ureters,  sacral  plexus 
of  nerves,  and  iliac  vessels  ;  it  also  invests  the  first  part  of 
the  rectum  and  forms  the  meso-rectum.  It  gradually  leaves 
the  sides  of  the  second  part  of  the  rectum  and,  passing  on 
to  the  upper  2  cm.  of  the  posterior  vaginal  wall,  extends 
over  the  whole  of  the  posterior  aspect  of  the  body  of  the 
uterus.  Continuing,  it  invests  the  fundus  and  anterior  sur- 
foce  of  the  body  of  the  uterus,  and  leaves  it  at  the  level  of 
the  internal  os  to  cover  the  posterior  surface  of  the  bladder, 
and  then  ascends  on  the  anterior  abdominal  wall.  As  the 
peritoneum  invests  the  uterus  a  fold  known  as  the  meso- 
metrium  (broad  ligament)  extends  from  each  side  of  it, 
which  becomes  continuous  with  the  peritoneum  investing 
the  iliac  fossa.  Thus  the  transverse  fold  formed  by  the 
uterus  and  its  mesometria  divides  the  pelvic  cavity  into  two 
recesses,  of  which  the  posterior  is  the  recto-vaginal  fossa 
[pouch  of  Douglas)  and  the  anterior  the  utero-vesical  fossa. 
It  will  be  necessary  to  study  these  fossae  and  the  meso- 
metrium  in  detail. 

The  Mesometrium. — This  important  fold  is  formed  by 
the  peritoneum  as  it  is  reflected  over  the  uterus  and  Fallo- 
pian tubes ;  it  consists  of  two  layers  of  serous  membrane. 
The  part  in  relation  with  the  uterus  and  tubes  has  the  fat 
of  the  subserous  tissue  replaced  by  unstriped  muscle  tissue, 
but  as  it  approaches  the  floor  of  the  pelvis  fat  again  appears 
in  relation  with  it.  The  mesometrium  lodges  between  its 
layers,  in  addition  to  the  Fallopian  tube,  the  ovary  with  the 
parovarium,  Gartner's  duct,  the  ligament  of  the  ovary,  the 
round  ligament  of  the  uterus,  the  ureter,  the  uterine  and 
ovarian  arteries,  the  pampiniform  plexus  of  veins,  and  the 
lymphatics  of  the  uterus :  these  structures  are  embedded 
in  loose  connective  tissue.  Two  strands  of  muscle  tissue, 
the  utero-sacral  ligaments,  pass  from  the  lateral  aspect  of 
the  cervix  to  the  sides  of  the  second  sacral  vertebra. 

The    upper   portion   of  the   mesometrium   is  called   the 


28  DISEASES   OE   WOMEN. 

mesosalpinx  ;  it  is  included  between  the  Fallopian  tube,  the 
tubo-ovarian  li^ranieiit,  the  ovary  and  the  ovarian  ligament, 
and  contains  between  its  layers  the  parovarium  and  the 
associated  sej^nient  of  Gartner's  duct,  the  ovarian  arterj'  and 
veins,  and  the  uterine  end  of  the  round  ligament  of  the 
uterus. 

The  Recto-vaginal  Fossa  {Poudi  of  Douglas). — This 
is  a  cul-de-sac  of  the  peritoneum  in  relation  with  the  floor  of 
the  pelvis,  situated,  as  its  name  indicates,  between  the  rec- 
tum and  the  upper  2  cm.  of  the  posterior  vai^nnal  wall  and 
the  cervix  uteri.  Laterally  the  upper  limits  of  this  jxjuch 
are  the  utero-.sacral  ligaments.  The  pouch  is  deeper  on  tlic 
left  than  the  right  side,  the  peritoneum  being  carried  down- 
ward by  the  rectum.  When  the  pouch  is  not  occupied  by 
intestine  or  omentum,  its  anterior  and  posterior  walls  are 
in  apposition. 

The  Utero-vesical  Fossa. — This  is  a  shallower  cul- 
de-sac  between  the  bladder  and  the  body  of  the  uterus.  Its 
depth  varies  with  the  empty  or  distended  condition  of  the 
bladder. 

The  Ovarian  Pouch. — This  is  a  shallow  recess  in  the 
posterior  layer  of  the  mesosalpinx.  It  varies  in  depth, 
being  small  and  inconspicuous  in  many,  whilst  in  others  it 
is  deep  enough  to  accommodate  the  entire  ovar)-.  In  the 
virgin  the  ampulla  of  the  tube  falls  over  the  mouth  of  the 
pouch  and  conceals  the  ovary. 

Canal  of  Nuck. — In  addition  to  the  two  fossae  actually 
within  the  pelvic  cavity,  there  is  a  peritoneal  pouch  directly 
connected  with  the  anterior  layer  of  each  mesometrium 
which  partially  invests  the  round  ligament  of  the  uterus 
and  accompanies  it  through  the  inguinal  canal  to  the  la- 
bium. This  pouch,  known  as  the  canal  of  Nuck,  normally 
becomes  obliterated  in  the  adult. 

In  order  that  the  student  may  thoroughly  comprehend 
the  relations  of  the  pelvic  peritoneum  it  will  be  useful  to 
summarize  briefl}'  the  manner  in  which  it  invests  the  parts  : 


ANATOMY  OF  RE  PRODUCT  I VE    ORGANS.  29 

1.  The  Ovary. — This  projects  from  the  posterior  layer 
of  the  mcsometrium  and  strictly  has  no  peritoneal  invest- 
ment. 

2.  The  Fallopian  Tube. — This  is  invested  on  two-thirds 
of  its  circumference.  The  tubal  ostium  communicates  with 
the  coelom  (peritoneal  cavity)  on  the  posterior  aspect  of 
the  mcsometrium,  below  the  ovary  and  near  the  brim  of  the 
pelvis. 

3.  The  Uterus. — The  peritoneum  covers,  posteriorly,  the 
whole  of  the  surface  of  the  body  and  fundus  of  the  uterus 
and  supravaginal  portion  of  the  cervix ;  anteriorly,  the  fun- 
dus and -body  to  the  junction  of  the  body  and  cervix.  The 
sides  of  the  uterus  are  in  relation  with  the  connective  tissue 
of  the  mcsometrium. 

TJie  Round  Ligament  of  the  Uterus. — In  the  pelvis  this 
structure  is  invested  by  the  anterior  layer  of  the  mcsome- 
trium. As  it  traverses  the  inguinal  canal  it  invaginates  the 
peritoneum  of  the  canal  of  Nuck. 

4.  The  Vagina. — The  only  part  of  this  tube  in  relation 
with  the  peritoneum  is  the  posterior  cul-de-sac. 


CHAPTER    II. 

THE    GENERAL    PHYSIOLOGY    OF    THE    REPRODUCTIVE 
ORGANS   OF   WOMEN. 

The  development,  maturity,  and  decline  of  the  reproduc- 
tive powers  in  a  healthy  woman  correspond  to  the  men- 
strual life,  the  beginning  of  which  is  termed  Puberty,  while 
its  termination  is  the  Menopause.  This  period  extends 
from  the  age  of  thirteen  to  that  of  forty-eight,  with  individ- 
ual variations.  Warm  climates,  sedentary  and  luxurious 
habits,  and  emotional  stimulation  are  associated  with  early 
puberty ;  late  puberty  is  commonly  found  in  the  opposite 
conditions.  Puberty  is  sometimes  defined  as  "  reproductive 
maturity ;"  but  it  must  be  remembered,  first,  that  concep- 
tion sometimes  occurs  before  menstruation  has  begun ; 
secondly,  that  the  uterus  continues  to  grow  till  about  the 
eighteenth  or  twentieth  year  and  the  woman  cannot  usu- 
ally be  considered  as  sexually  mature  till  this  time. 

The  external  indications  of  approaching  puberty  are : 
enlargement  of  the  breasts  (mammse),  development  of  hair 
in  the  axillae  and  on  the  mons  Veneris  ;  subjective  sensa- 
tions such  as  fulness  of  the  pelvis,  backache  and  shooting 
pains  in  the  thighs,  and  lastly  some  alteration  in  the  dis- 
position, in  the  direction  of  shyness  and  reserve.  The 
actual  establishment  of  puberty  is  reckoned  from  the  first 
menstruation. 

MENSTRUATION. 

I.  Clinical   Features. — After    the    first    menstruation, 
which  may  be   rather  abundant,  it  is  not  unusual  for  a  pe- 
so 


PHYSIOLOGY  OF  REPKODUCTIVE    ORGANS.  3 1 

riod  of  irregularity  to  succeed  ;  then  after  some  months  the 
process  assumes  its  regular  rhythmic  form.  The  periodicity 
varies  with  individuals,  and  in  the  same  individual  at  differ- 
ent times  ;  most  frequently  twenty-eight  to  thirty  days 
elapse  between  the  commencement  of  one  period  and  the 
commencement  of  the  next.  The  total  quantity  of  blood 
lost  at  each  monthly  period  varies  from  two  to  three 
ounces  (60  to  90  c.cm.)  and  the  flow  lasts  from  two  to  seven 
days.  Sometimes  on  the  third  or  fourth  day  it  ceases,  to 
recommence  in  diminished  quantity  after  twenty-four  hours 
for  another  two  or  three  days.  A  discharge  of  mucus 
commonly  precedes  and  follows  that  of  blood.  The  latter 
has  all  the  characteristics  of  ordinary  venous  blood,  except 
that  it  does  not  coagulate,  owing  to  admixture  with  mucus 
from  the  cervical  canal ;  it  also  contains  epithelium  derived 
from  the  uterus  and  vagina.  When  abundant,  it  may  be 
bright  red,  and  clots  may  form.  Under  favorable  condi- 
tions menstruation  is  painless,  especially  for  the  first  few 
years.  Later,  and  in  some  cases  from  the  first,  an  aching 
pain  in  the  sacrum  precedes  the  flow,  passing  off  as  this 
becomes  established.  Suprapubic  pain  may  either  precede 
or  accompany  the  flow — generally  the  latter.  In  London 
about  30  per  cent,  of  women  continue  to  menstruate  pain- 
lessly. The  intensity  of  the  pain  varies  from  slight  discom- 
fort to  intense  agony  preventing  the  woman  from  getting 
about  or  from  attending  to  her  ordinary  pursuits.  No 
hard-and-fast  line  can  be  drawn  between  normal  menstrua- 
tion and  dysmenorrhoea.  Similarly,  there  is  great  varia- 
tion in  the  nature  and  amount  of  constitutional  disturbance; 
headache,  lassitude,  sickness,  obscure  reflected  pains  are  not 
infrequent,  with  mental  depression  or  irritibility.  Lastly, 
in  a  few  cases  the  general  health  is  better  than  during  the 
intermenstrual  periods. 

II.  Anatomical  and  Physiological  Changes. — 
A.  Ovulation. — This  signifies  the  ripening  and  escape  of 
ova  from  the  ovaries.     When  these   glands  (which   are  the 


32 


DISEASES   OE   WOMEN. 


dominant  organs  of  reproduction  in  women)  fail  to  develop, 
sterility  results,  and  the  woman  generally  retains  the  physi- 
cal characters  of  the  child.    Thus  the  breasts  are  small,  the 


Dehiscence  of 
a  ripe  ovum. 


Ovum. 


Uvttm:-         \         ^Membrana  gr,-.' 
Discus  proUgerus. 

Fig.  5. — Diagram  illustrating  ovulation  ;  ovary  of  the  rabbit  (A.  E.  G.). 

pubic  hair  is  scanty  or  absent,  and  the  pelvis  is  narrower 
than  usual,  whilst  menstruation  does  not  occur  or  is  much 
delayed.    With  the  onset  of  puberty  the  ovaries,  previously 


PHYSIOLOGY  OF  REPRODUCTn'E    ORGANS.  33 

small,  enlarge  and  exhibit  the  periodic  series  of  changes 
known  as  ovHlatio)i. 

Ovulation  consists  in  the  growth  and  shedding  of  an 
ovum,  which  first  sinks  more  deeply  into  the  stroma,  and 
then  approaches  the  surface  of  the  ovary ;  the  follicle  in 
which  the  ovum  is  contained  bursts,  and  the  ovum  itself  is 
discharged.  Normally  it  finds  its  way  into  the  Fallopian 
tube  and  is  propelled  along  it  to  the  uterus  ;  should  the 
ovum  be  fertilized  it  develops  into  an  embryo.  Failing  this, 
it  passes  out,  probably  with  the  menstrual  discharges. 

The  process  of  ovulation  will  be  readily  understood  by 
a  reference  to  the  accompanying  diagram  (Fig.  5)  repre- 
senting its  successive  stages.  From  this  it  will  be  seen  that 
a  given  ovum  first  becomes  surrounded  by  a  layer  of  small 
cells,  to  form  an  ovarian  (Graafian)  follicle.  At  the  same 
time  the  stroma  bounding  the  follicle  becomes  denser.  On 
one  side  of  the  ovum  a  line  of  cleavage  occurs  in  the 
middle  of  the  surrounding  cells,  and  the  space  is  found  to 
contain  fluid.  The  ovarian  follicle  now  presents  an  appear- 
ance which  has  been  compared  to  a  signet  ring  ;  the  margi- 
nal cells  receive  the  name  of  membrana  granulosa, 
whilst  those  immediately  surrounding  the  ovum  are  called 
the  discus  proligerus.  As  the  follicle  grows  it  approaches 
the  surface  of  the  ovary,  and  its  envelope  becomes  vascu- 
lar from  enlargement  of  vessels  derived  from  the  stroma. 
The  ripe  follicle  bulges  on  the  surface  ;  the  most  promi- 
nent point,  which  is  non-vascular,  gives  way  and  the  ovum 
escapes,  surrounded  by  the  discus  proligerus.  This  consti- 
tutes the  dehiscence  of  the  ovum.  The  cavity  of  the  fol- 
licle becomes  filled  with  blood,  derived  from  the  vessels  in 
its  capsule,  and  the  capsule  itself  contracts  in  folds.  The 
blood-filled  cavity  with  its  convoluted  walls  is  called,  from 
its  yellow  appearance,  the  corpus  luteum  (Fig.  6).  By 
degrees  the  liquid  part  of  the  blood  is  absorbed.  The  cor- 
pus luteum  becomes  paler  and  shrinks  and  is  converted 
into  cicatricial  tissue  whose  only  ultimate  trace  is  a  scar 
3 


34 


DISEASES   OE   WOMEN. 


or  cicatrix  on  tlit.'  surface  of  the  ovarj'.  \\y  the  rejx-ti- 
tioii  of  this  process,  the  smooth  apj^earance  of  the  )'ouii^r 
ovary  is  replaced  by  the  ru^^ed  aspect  of  the  ovary  of  the 
adult. 

When  pret^naucy  occurs,  the  corpus  luteum,  instead  of 
reachinj^  its  fullest  development  in  three  weeks  and  disap- 
pearin<:j  in  three  months,  persists  in  a  well-developed  form  for 
three  or  four  months,  after  which  it  gradually  diminishes,  and 
commonly  disappears  in  two  or  three  months  after  delivery. 

Probably  a  certain  number  of  ova  fail,  on  their  dehis- 
cence, to  enter  the  Fallopian  tube,  and  are  lost  in  the  cce- 
lom  (peritoneal  cavity).     Maturation  (ripening)  of  ova  may 


Fig.  6. — Stages  in  the  formation  of  a  corpus  luteum  :  A,  recent  blood ;   B,  ilic  wrinkling  of 
its  walls  ;  C,  contracting  stage  (A.  E.  G.). 


occur  before  puberty,  and  ripe  ova  have  been  detected  in 
the  ovaries  at  birth.  The  view  formerly  held,  that  an  ovum 
ripens  at  each  menstrual  period,  is  now  abandoned  by  most 
authorities.  Nor  is  there  any  evidence  that  ovulation  occurs 
alternately  in  the  two  ovaries  ;  there  is  apparently  no  con- 
stant relation  in  the  activity  of  the  two  glands. 

B.  CJiangcs  in  the  Uterus. — The  only  part  of  the  uterus 
which  shows  menstrual  changes  is  that  between  the  inner 
orifices  of  the  Fallopian  tubes  and  the  internal   os.     The 


PHYSIOLOGY  OF  RErKODUCTrVE    ORGANS.  35 

Fallopian  tubes  themselves  take  no  part  therein  (Sutton, 
Heape).  The  preeise  nature  of  the  chancres,  which  affect 
the  mucosa  alone,  has  been  much  disputed.  The  classical 
views  have  been  as  follows  : 

{a)  That  the  whole  thickness  of  the  mucosa,  down  to  the 
muscular  layer,  is  stripped  off  and  shed  at  each  monthly 
period  (Pouchet,  Williams). 

ib)  That  the  surface  epithelium  only  is  cast  off  (Leopold, 
Kundrat  and  Engelmann). 

[c]  That  the  mucous  membrane  remains  quite  intact 
(Coste,  Moricke). 

The  difficulty  of  obtaining  specimens  of  the  healthy 
menstruating  uterus  has  led  to  this  divergence  of  views. 
There  is,  however,  reason  to  believe  that  in  some  of  the 
higher  apes  the  process  closely  resembles  that  which  occurs 
in  women  ;  and,  basing  our  description  partly  on  compara- 
tive observations  (Sutton,  Heape)  and  partly  on  researches 
on  the  human  uterus,  the  changes  are  as  follows  : 

The  mucosa  of  the  non-menstruating  uterus  is  composed 
of  a  stroma  containing  numerous  glands  and  blood-vessels, 
and  covered  by  a  single  layer  of  cubical  epithelium.  Shortly 
before  menstruation  begins  the  stroma-cells  proliferate  and 
the  superficial  vessels  become  dilated ;  with  increased  con- 
gestion the  dilated  capillaries  break  down  and  blood  is 
extravasated  into  the  superficial  parts  of  the  stroma  under 
the  epithelium.  Later  the  epithelium  gives  way,  probably 
in  part  from  a  degenerative  change,  and  is  cast  off,  along 
with  portions  of  the  stroma  and  of  the  glandular  epithelium. 
The  debris  passes  out  with  the  menstrual  fluid.  After  a 
time,  regeneration  of  the  mucosal  surface  takes  place,  by 
re-formation  of  blood-vessels  and  by  the  reproduction  of 
epithelium,  partly  from  the  torn  edges  of  the  glands  and 
partly  by  the  transformation  of  stroma  elements  (Heape). 

During  menstruation  there  is  a  slight  spontaneous  dilata- 
tion of  the  cervical  canal,  attaining  its  maximum  on  the 
third  and  fourth  days  (Herman). 


36  DISEASES   OF   WOMEN. 

111.  The  Significance  of  Menstruation. — Wc  need 
not  refer  here  to  old  theories,  which  are  merely  of  historic 
interest.  The  first  attempt  to  explain  menstruation  from  the 
facts  of  anatomy  and  physiology  resulted  in  the  Oi'ulaliou 
Theory,  which  supposes  that  regularly,  every  month,  an 
ovum  ripens  and  is  set  free,  leading  to  uterine  congestion 
and  menstruation.  This  theory,  which  was  widely  held 
during  the  second  quarter  of  this  century,  through  the 
work  of  Lee,  Negrier,  Bischoff  and  Raciborsky,  is  now 
generally  discarded ;  for  repeatedly  instances  have  occurred 
where  menstruation  has  recently  happened  and  there  has 
been  no  trace  of  the  ripening  of  an  ovum ;  and,  on  the 
other  hand,  where  ripe  follicles  and  recent  corpora  lutea  are 
present  and  menstruation  has  not  been  established,  or  has 
ceased,  or  is  in  abeyance.  An  explanation  has  therefore 
been  sought  in  the  periodic  variations  of  nutrition,  as 
shown  by  the  pulse,  temperature,  blood-pressure,  and  the 
quantity  of  urea  excreted.  This  is  the  Cyclical  Theory 
(Jacobi,  Goodman,  Reinl,  and  others).  The  existence  of  the 
variations  is  established ;  but  that  they  are  the  cause  of 
menstruation,  is  not. 

Probably  the  simplest  way  to  regard  the  whole  matter  is 
as  follows  :  The  female  organism  presents  a  tendency  to  an 
alternation  of  nutritive -and  reproductive  activity.  The 
alternation  has  a  monthly  rhythm ;  but  to  inquire  why, 
is  as  fruitful  as  to  ask  why  the  respiratory  rhythm  should 
be  about  four  seconds  or  the  cardiac  cycle  something  under 
one  second. 

Periodically,  then,  the  body  prepares  itself  to  take  on 
reproductive  functions  ;  in  this  preparation  the  vaso-motor 
system  acts  as  chief  agent,  as  shown  in  variations  of  tem- 
perature, pulse,  and  nervous  manifestations,  as  well  as  in 
ovarian  and  uterine  changes.  The  latter  are  directed  to 
the  protection  and  nutrition  of  a  developing  ovum,  for  the 
changes  preceding  menstruation  correspond  closely  to  the 
early  stages  in  the  formation   of  the  decidua  of  pregnancy. 


PHYSIOLOGY  OF  REPRODUCTIVE    ORGANS.  37 

If,  however,  no  fertilized  ovum  be  ready,  a  miniature  abor- 
tion occurs,  for  the  nidus  of  the  early  embryo  must  always 
be  freshly  prepared.  After  the  menstrual  discharge,  the 
uterus  begins  its  preparations  anew.  Menstruation,  there- 
fore, is  a  missed  pregnancy. 

The  Menopause. — The  onset  of  the  menopause  pre- 
sents very  varied  features.  In  some  women  there  is  no 
disturbance  at  all ;  menstruation  goes  on  normally  and  then 
simply  ceases,  without  prodromata ;  this  occurs  most  often 
among  unmarried  women.  In  other  cases  menstruation 
becomes  irregular  in  its  periodicity,  while  the  quantity 
becomes  variable ;  after  an  unusually  long  interval  there  is 
a  final  and  rather  profuse  flow,  and  the  menopause  is  estab- 
lished without  any  constitutional  trouble.  But  in  the 
majority  of  women  the  "change  of  life"  is  not  so  easily 
effected.  Various  nervous  phenomena  appear ;  the  patient 
is  subject  to  hot  flushes,  attacks  of  giddiness,  obscure  pains 
in  breasts,  abdomen,  and  limbs.  Digestion  is  disordered, 
with  flatulence  and  constipation.  There  is  a  great  tendency 
to  deposits  of  fat,  which,  with  the  flatulence,  may  cause 
"  spurious  pregnancy,"  or  a  phantom  tumor.  Many  women 
become  depressed,  and  unstable  minds  may  cross  the 
border-line  of  insanity.  It  is,  therefore,  with  many,  really 
a  "  critical  period,"  demanding  careful  supervision. 

The  pelvic  organs  show  corresponding  anatomical 
changes.  The  ovaries  become  smaller  and  wrinkled ;  the 
vagina  contracts  and  assumes  the  shape  of  a  cone,  at  the 
apex  of  which  is  a  dimple  representing  the  os  uteri, — for 
all  the  vaginal  portion  of  the  cervix  atrophies  and  disap- 
pears. The  uterine  body  diminishes  in  size,  and  in  extreme 
cases  can  hardly  be  felt. 


CHAPTER    III. 

METHODS   OF   EXAMINATION   UF    THE   FEMALE   I'ELVIC 

ORGANS. 

Accurate  diagnosis  is  not  a  matter  of  intuition.  It  de- 
pends on  a  scientific  intcrjjictation  of  physical  signs  and  of 
symptoms. 

The  value  of  symptoms  is  threefold.  They  determine, 
first  the  necessity,  and  secondly  the  meth(jd  of  examina- 
tion ;  thirdly,  they  influence  the  interpretation  of  signs. 

The  value  of  physical  signs  is  that  they  are  of  the  nature 
of  facts ;  for  their  discovery,  training  and  a  systematic 
method  are  essential.  This  chapter  is  concerned  with  the 
exposition  of  a  systematic  method;  whilst  the  student  will 
obtain  his  training  by  the  application  of  the  method  in  the 
out-patient  room  and  by  the  bedside. 

Abdominal  Examination. — This  should  alwa)'s  be 
made  first,  in  the  classical  order :  Inspection,  Palpation, 
Percussion,  Auscultation. 

Inspection. — This  shows  the  size  of  the  abdomen,  and 
may  reveal  striae,  pigmentations,  prominence  of  superficial 
veins,  irregularities  of  surface,  as  evidence  of  past  or  present 
distention  or  of  intra-abdominal  pressure. 

Palpation  shows  in  the  first  place  the  resistance  of  the 
abdominal  walls,  and  when  carried  deeper  will  give  infor- 
mation as  to  the  enlargement  of  particular  organs  or  of 
certain  parts  of  the  abdomen.  If  there  be  any  abdominal 
tenderness  this  is  also  revealed.  It  is  often  necessary  to 
ascertain  the  condition  and  relations  of  the  liver,  stomach, 
spleen,  and  kidneys.  Palpation  is  also  most  important  in 
38 


exam/jVation  of  pelvic  organs.  39 

pregnancy.  In  the  absence  of  a  tumor  occupying  the  pel- 
vic inlet,  the  sacral  promontory  can  be  easily  reached. 

Parussion  indicates  the  nature  of  local  or  generalized 
abnormalities  discovered  by  palpation  ;  solid,  liquid  or  gas- 
eous local  conditions  may  thus  be  analyzed,  and  the  size 
and  distribution  of  tumors  or  of  collections  of  fluid  may 
be  ascertained.  A  loaded  colon,  often  of  significance, 
will  sometimes  be  discovered  by  this  and  the  preceding 
method. 

Ausailtatioii  has  also  its  value,  chiefly  in  pregnancy  and 
in  certain  uterine  tumors  where  a  venous  murmur  may  be 
heard. 

In  conducting  the  above  inquiries  the  position  of  the 
patient  may  require  to  be  changed ;  she  may  be  turned  to 
one  or  the  other  side,  or  the  knees  may  be  drawn  up  in 
order  to  relax  the  abdominal  muscles. 

Inspection  of  the  external  genitals  is  often  unnecessary, 
at  least  in  the  first  instance,  whilst  in  other  cases  it  will  be 
indicated  by  the  nature  of  the  symptoms  complained  of 

Vaginal  Bxamination. — For  this  purpose  the  patient 
may  lie  on  her  back  or  side. 

The  Dorsal  Position. — We  take  this  first  because  it  is 
the  best  for  a  complete  pelvic  examination.  It  is  often 
convenient  to  let  the  patient  retain  the  position  in  which 
the  abdominal  examination  was  made,  the  knees  being 
drawn  up. 

The  right  hand  is  used  for  the  vaginal  exploration,  and 
the  left  for  abdominal  palpation,  the  physician  standing  on 
the  right  side  of  the  patient.  Or,  if  more  convenient,  the 
patient  is  placed  at  the  foot  or  side  of  the  bed,  with  knees 
drawn  up  and  everted,  the  physician  standing  or  sitting 
opposite  the  perineum.  In  either  case  the  examination  is 
made  in  the  same  systematic  manner. 

The  index  finger,  well  lubricated,  is  introduced  into  the 
vagina  by  gently  feeling  for  the  perineum,  and  passing 
forward  till  the  posterior  margin   of  the  vaginal   outlet  is 


40  D/SIiASF.S   OF   WOMEN. 

reached.  In  the  vagina,  the  finder  should  press  chiefly 
against  the  posterior  wall.  It  must  be  remembered  that 
the  direction  of  the  vay^ina  is  toward  the  body  of  the  first 
sacral  vertebra.  After  the  character  of  the  vaginal  walls 
and  of  the  cervix  have  been  noted,  the  left  hand  is  placed 
on  the  abdomen,  to  make  the  bimanual  examination. 
The  abdominal  wall  is  depressed  just  above  the  pubes,  the 
fingers  being  placed  as  flat  as  possible  to  avoid  hurting 
the  patient  with  the  nails  or  finger  tips.  The  position  of 
the  pelvic  brim  must  be  remembered;  for  exploration  of  the 
posterior  regions  of  the  pelvis  the  hand  will  have  to  be 
placed  nearer  the  umbilicus  ;  similarly,  it  must  be  moved  to 
one  or  other  side  in  examining  the  lateral  parts  of  the  pel- 
vis. As  the  external  hand  is  moved,  the  finger  in  the 
vagina  is  moved  at  the  same  time,  passing  into  the  anterior, 
posterior,  or  lateral  vaginal  fornices,  in  order  to  meet  the 
external  fingers ;  and  gentle  pressure  must  be  made  till  the 
inside  and  outside  fingers  meet,  or  till  some  definite  struc- 
ture is  felt  between  them. 

In  women  who  have  borne  children  it  is  generally  better 
to  use  two  fingers  for  the  vaginal  examination,  because  we 
can  thus  reach  higher  up,  and  a  better  idea  is  obtained  of 
the  position  of  the  organs. 

Still  using  the  dorsal. position,  ^  rccto-abdonii)ial  cxavii- 
nation  may  be  required,  either  in  the  first  instance  in  \irgins 
or  to  give  additional  information  in  others.  Much  may  be 
made  out  by  this  method  :  the  general  size,  position,  and 
shape  of  the  uterus  can  be  determined,  the  posterior  surface 
of  the  uterus  exjilored,  and  the  appendages  often  distinctl)' 
mapped  out. 

In  certain  cases  a  rccto-vagi)ial-abdo]iii>ial  cxavimatiou  is 
resorted  to  ;  this  is  especially  useful  in  defining  exudations 
or  solid  bodies  in  the  recto-vaginal  fossa,  for  vaginal  touch 
alone  might  suggest  that  these  were  in  the  rectum,  while 
rectal  exploration  alone  might  give  the  impression  that 
they  were  in  the  vagina  or  connected  with  the  uterus. 


EXAMINATION  OF  PELVIC   ORGANS.  4 1 

TJic  Lateral  Position. — The  patient  lies  on  the  left  side, 
with  buttocks  projecting  over  the  edge  of  the  bed,  and 
with  the  knees  drawn  up.  In  this  position  the  relation  of 
parts  is  not  so  clear,  and  the  beginner  will  more  readily 
make  mistakes.  It  is  well,  however,  to  accustom  oneself 
to  both  methods,  and  in  certain  cases  it  is  useful  to  employ- 
both  in  turn.  But  for  some  purposes  the  lateral  position 
answers  all  requirements,  especially  when  the  bimanual 
examination  is  not  necessary ;  whilst  for  some  manipula- 
tions, both  for  diagnosis  and  for  treatment,  it  is  preferable. 

The  litlwtomy  position,  with  pelvis  raised  and  knees  flexed 
on  the  abdomen,  is  seldom  required  for  an  examination, 
unless  under  an  anaesthetic. 

The  semi-prone  position,  or  Sims',  is  useful  when  it  is 
required  to  examine,  with  the  speculum  or  otherwise,  the 
anterior  vaginal  wall,  and  sometimes  for  purposes  of  treat- 
ment. The  patient  lies  on  her  left  side,  and  partly  prone; 
both  knees  are  drawn  up,  the  right  in  front  of  the  left. 
The  patient's  chest  lies  almost  flat  on  the  pillow,  the  left 
arm  is  placed  behind  her  or  hangs  over  the  edge  of  the 
bed. 

The  genii-pectoral  position  is  occasionally  required  ;  for 
instance,  to  replace  a  retroverted  gravid  uterus.  The  pa- 
tient rests  on  her  chest,  arms,  and  knees,  the  pelvis  being 
raised  and  the  thighs  vertical. 

We  have  so  far  traced  the  methods  to  be  adopted,  and 
the  information  that  may  be  obtained,  in  using  the  hands 
alone.  We  must  now  pass  under  review  the  various  acces- 
sory procedures,  with  the  aid  of  instruments.  Of  these  the 
most  important  is  the  uterine  sound. 

The  Uterine  Sound. — This  is  a  rod  of  copper,  silver- 
plated,  rigid  enough  to  retain  any  shape  imparted  to  it,  and 
flexible  enough  to  admit  of  being  bent  with  the  fingers. 
It  is  set  on  a  handle  which  is  flattened,  and  rough  on  one 
surface  (Fig.  7).  The  sound  is  straight  in  the  portion 
next  the  handle ;  the  distal  portion  is  curved,  the  concavity 


42 


DISEASES   OE   IfOMEX. 


being  on  the  same  .side  as  the  rough  surface  of  the  handle. 

The  curve  is  of  such  a  nature  that 
the  last  2^  in.  (6.2  cm.)  form  an 
angle  of  about  140°  with  the 
straight  portion;  and  at  the  junc- 
tion of  these  two  parts  there  is  a 
well-marked  knob  or  angle  on  the 
convex  side,  which  can  be  readily 
distinguished  by  the  finger,  and 
which  marks  the  distance  to  which 
the  sound  should  enter  a  normal 
uterus.  The  instrument  is  gradu- 
ated by  means  of  notches  on  the 
convex  side.  The  first  notch  is  i  \ 
in.  (3.7  cm.)  from  the  tip ;  the  knob 
or  angle  forms  the  next  mark,  2^ 
in.  (6.2  cm.)  from  the  tip,  and  the 
remaining  notches  are  i  in.  (2.5 
cm.)  apart ;  the  first  being  3I  in. 
(8.7  cm.)  from  the  tip.  The  length 
of  the  uterine  canal  is  easily  meas- 
ured by  placing  the  finger  on  the 
point  just  outside  the  external  os 
when  the  sound  has  passed  as  far 
as  it  will,  and  keeping  the  finger  in 
its  place  while  the  sound  is  being 
withdrawn.  The  distance  is  read 
off  by  means  of  the  graduation 
notches. 

The  sound  should  not  be  used 
when  the  patient  has  missed  a 
menstrual  period,  unless  preg- 
nancy be  certainly  excluded ; 
when  there   is  any   pelvic   inflam- 

FlG.  7. —  I  he  utcriiic  sound. 

mation,   malignant  disease  of  the 
uterus,  or  when  the  vagina  or  cervix  is  septic.     All  these 


EXAMINATION  OF  PELVIC   ORGANS.  43 

points  can  be  determined  by  the  preliminary  digital  ex- 
aminations. 

Hoiv  to  Use  the  Sound. — It  is  most  important  that  the 
position  and  direction  of  the  uterus  should  be  first  deter- 
mined, so  that  if,  for  instance,  the  uterus  is  strongly  flexed, 
a  little  additional  curve  maybe  first  imparted  to  the  sound  ; 
if  the  organ  be  lying  much  ante-  or  retroverted,  an  idea 
can  be  gained  beforehand  of  the  general  direction  that  the 
sound  will  take.  This  settled,  the  finger  is  placed  so  as  to 
rest  against  the  os,  and  the  point  of  the  sound  is  carried 
along  the  concavity  of  the  finger  and  guided  by  it  into  the 
cervical  canal.  Once  entered  (a  matter  of  little  difficulty, 
as  a  rule),  the  handle  of  the  sound  is  to  be  carried  gently 
back  to  the  perineum.  In  most  cases  this  will  suffice  to 
cause  the  end  of  the  sound  to  slip  through  the  os  internum. 
No  pressure  need  be  used.  But  if  the  uterus  is  retro- 
verted, the  concavity  of  the  sound  should  first  be  directed 
backward,  and  by  moving  the  handle  slightly  forward  the 
sound  enters  the  cavity.  In  some  cases,  when  there  is 
lateral  deviation  of  the  uterus,  or  when  the  canal  is  tortuous 
(as  when  a  myoma  is  present),  a  little  patience  and  care  will 
be  needed.  But  always  desist  rather  than  use  force.  The 
introduction  of  the  sound  is  sometimes  facilitated  by  taking 
hold  of  the  anterior  lip  of  the  cervix  with  a  volsella,  and 
drawing  it  gently  down. 

Information  Given  by  the  Sound. — It  is  possible  to  intro- 
duce and  withdraw  a  sound,  and  to  realize  little  but  the  fact 
of  its  introduction ;  but,  used  as  an  extended,  sensitive 
finger,  it  will  teach  much.  At  the  outset  the  degree  of 
patency  of  the  os  will  be  noted,  the  smoothness  or  other- 
wise of  the  cervical  canal,  and  the  existence  (if  present)  of 
muscular  spasm  at  the  os  internum  ;  one  gets  also  a  general 
idea  of  the  firmness  or  flabbiness  of  the  tube,  through  which 
the  sound  is  passing.  The  sound  once  introduced,  the 
length  of  the  ca\'it\'  can  be  measured,  and  by  gentle  rota- 
tory movement  its  width  may  be  gauged.     Projections  may 


44  DISKASIS   OF   WOMEN. 

be  met  with,  as  sessile  tumors,  which  at  first  obstruct  the 
passage  of  the  sound.  Sometimes,  also,  two  distinct  direc- 
tions will  be  found  in  which  the  sound  passes,  as  in  a  bipar- 
tite uterus.  Meanwhile  the  patient  will  herself  have  given 
some  indications ;  at  certain  points  she  may  complain  of 
pain,  as  in  passing  through  the  internal  os,  or  when  touch- 
ing the  fundus.  If  the  bimanual  examination  has  revealed 
a  tumor  it  will  now  be  noted  whether  the  sound  passes 
into  it  or  not,  and  in  the  latter  case  whether  movements  of 
the  sound  are  at  once  conveyed  to  the  tumor  or  vice  versa; 
in  this  way  a  uterine  can  often  be  distinguished  from  a  non- 
uterine  tumor.  When  the  tumor  is  uterine,  by  placing  one 
finger  in  the  anterior  and  the  other  in  the  posterior  fornix, 
or  with  one  finger  in  each  lateral  fornix,  it  may  be  possible 
to  determine  whether  the  tumor  is  in  the  anterior,  posterior, 
or  side  wall  of  the  uterus. 

As  the  sound  is  withdrawn,  it  may  be  felt  to  be  gripped, 
either  by  spasm  or  by  mere  narrowness  of  the  passage ;  we 
have  here  the  test  of  stenosis.  If,  while  the  sound  is  intro- 
duced as  far  as  possible,  the  finger  be  placed  on  it  up  against 
the  cervix,  and  it  be  kept  in  this  position  when  the  sound  is 
withdrawn,  the  length  of  the  cavity  can  be  exactly  read  ofif. 
Lastly,  we  look  at  the  sound,  to  see  if  its  introduction  has 
caused  bleeding. 

The  Volsella. — This  is  principally  an  instrument  for 
treatment,  but  may  be  required  also  for  diagnosis.  It  is 
used  to  draw  the  cervix  down,  and  is  generally  applied  to 
the  anterior  lip.  In  most  cases  an  antero-posterior  grasp 
of  the  anterior  lip  is  obtained  ;  but  in  nullipara;  with  a  small 
cervi.x  it  is  often  more  convenient  to  seize  the  lip  trans- 
versely. When  the  uterine  canal  is  bent,  traction  on  the 
cervix  tends  to  straighten  it,  and  thus  facilitates  the  intro- 
duction of  the  sound.  The  ordinary  volsella  (Fig.  8)  is 
slender,  with  thin  hooks  ;  for  obtaining  a  firm  hold,  as  when 
the  uterine  canal  is  being  dilated,  the  bulldog  volsella  (Fen- 
ton's)  is  a  very  convenient  instrument. 


EXAMINATION   OF  PELVIC   ORGANS.  45 

In  removiiiL^  a  volsella,  care  is  required  lest  the  vagina 
be  caught  and  torn. 


Fig.  8. — Bulldog  volsella  ;  slender  volsella. 


The  Speculutn. — Introduced  as  an  instrument  of  diag- 
nosis, the  specukim  has  now  become  an  appHance  for 
treatment.  There  is  very  little  that  a  speculum  shows  that 
cannot  be  discovered  by  touch.     It  is  convenient,  however, 


46 


DISEASES   OF   WOMEN. 


to  sec  at  times  the  condition  of  tlic  vagina  and  the  cerxix. 
The  simplest  is  the  cylindrical  or  Fcrgtisson's  spcculnm 
(Fig.  9).  This  is  a  hollow  cylinder  of  stout  glass,  silvered 
like  a  mirror  and  coated  with  vidcanite.  Its  extremity  is 
bevelled  and  is  very  liable  to  chip.  When  this  happens  it 
will  scratch  the  patient  and  cause  j)ain.  To  introduce  it, 
the  instrument  is  warmed  and  lubricated  with  oil  or 
\aseline  and  the  perineum  is 
held  backward  while  the  end 
o{  the  speculum  is  pressed 
against  it.  The  instrument  is 
gently  pushed  in  the  direction 
of  the  vaginal  axis.  If  care  be 
taken  to  avoid   pressure  ante- 


FiG.  9. —  Fcrgusson's  speculum. 


Fig.  10. —  The  duckbill  (Sims')  speculum. 


riorly  against  the  pubes,  and  if  a  suitable  size  be  chosen 
the  procedure  causes  no  pain.  As  the  speculum  passes  up, 
a  general  view  is  obtained  of  the  vaginal  walls,  and  finally 
the  cervix  comes  into  view.  If  the  uterus  is  lying  forward, 
the  anterior  lip  of  the  cervix  may  alone  be  visible,  until  this 
is  drawn  down  with  a  tenaculum  or  volsella.  In  other  po- 
sitions of  the  uterus  the  inferior  surface  of  the  cer\'ix  comes 


EXAMINATION  OF  PELVIC    ORGANS.  47 

fully  into  view.  A  small  swab  of  cotton-wool  should  be  at 
hand  to  clear  away  the  mucus  and  blood  (if  any)  from  the 
surface  of  the  cervix  ;  this  can  then  be  examined  with  ease. 

The  duckbill  (^SiJns')  speculum  (Fig.  lo)  can  be  used  only 
in  the  semi-prone  or  the  lithotomy  position,  and  requires  an 
assistant  to  hold  it.  By  its  means  a  good  view  can  be  ob- 
tained of  the  anterior  vaginal  wall  and  of  the  cervix. 

The  bivalve  [Cusco's)  speculum  is  easy  to  introduce,  and 
allows  of  considerable  separation  of  the  two  free  ends, 
whilst  the  part  embraced  by  the  vulvar  outlet  is  not  further 
distended.  A  good  view  of  the  vaginal  walls  may  be  ob- 
tained by  slightly  rotating  the  instrument.  It  has  the  dis- 
advantage of  complexity  of  screw  and  hinges,  making  it  a 
matter  of  difficulty  to  keep  it  perfectly  clean. 

Neugebauers  specuhim  is  one  of  the  most  generally  con- 
venient. The  larger  posterior  blade  is  first  introduced,  well 
lubricated ;  the  smaller  blade  lies  within  the  larger,  the  two 
together  forming  a  cylinder  where  they  touch.  Any  degree 
of  separation  of  the  inner  ends  of  the  speculum  can  be  ob- 
tained that  may  be  desired  ;  a  good  view  of  the  cervix  can 
be  obtained,  and  by  using  one  blade  alone  the  anterior  or 
posterior  vaginal  wall  can  be  explored. 

A  very  useful  instrument  is  Auvard's  specidum.  It  is  on 
the  principle  of  Sims'  speculum,  but  is  made  "  self-retain- 
ing "  by  means  of  a  weight  on  the  handle.  The  handle 
itself  is  grooved,  so  that  it  can  be  used  as  a  conduit  for 
fluids  when  the  vagina  is  being  douched.  Its  special  value, 
however,  is  for  purposes  of  operation  ;  it  can  only  be  used 
with  the  patient  in  the  lithotomy  position. 

It  is  sometimes  necessary  to  include  in  one's  examination 
the  digital  exploration  of  the  interior  of  the  uterus.  Ex- 
cept immediately  or  soon  after  confinement  or  miscarriage, 
or  when  the  cervix  is  dilated  by  a  tumor  (polypus),  this  can 
only  be  done  under  an  anaesthetic,  and  the  cervical  canal 
must  be  dilated.  Tents  were  formerly  used  for  this  purpose, 
but  they  are  always  tedious  and  often  unsafe,  and  except  in 


48  DISEASES    OF   WOMEN. 

special  circumstances  it  is  better  to  carry  out  dilatation  at 
one  sitting. 

Examination  under  an  Anaesthetic. — We  would 
lay  special  stress  on  the  importance  of  this  as  an  aid  to 
exact  diagnosis.  In  the  case  of  unmarried  girls  and  nulli- 
parous  women  with  narrow  vagina  it  is  especially  indicated ; 
partly,  in  the  former  case,  for  ethical  reasons.  That  it  may 
be  satisfactory,  the  rectum  should  be  first  emptied  by  means 
of  an  enema,  and  the  urine  drawn  off,  if  necessar)',  by 
catheter. 

The  first  advantage  is  the  avoidance  of  pain ;  as  a  con- 
sequence the  examination  can  be  much  more  thorough, 
and  deep  pressure  exerted  as  required.  In  the  second  place 
the  muscular  relaxation  allows  of  a  much  better  bimanual 
examination.  There  should  be  no  difficulty,  in  an  ordinary 
case,  in  exactly  mapping  out  the  position  of  the  uterus, 
ovaries,  and  tubes.  The  differential  diagnosis  of  pelvic 
conditions  from  one  another  and  from  renal  and  other 
abdominal  tumors  is  comparatively  easy. 

Small  pelvic  swellings  are  often  easily  overlooked  in  an 
ordinary  examination ;  whilst  an  examination  under  an 
anaesthetic  in  the  lithotomy  position  will  generally  dis- 
cover them  without  trouble.  In  addition,  the  bladder  and 
rectum  can,  if  necessary,  be  thoroughly  explored. 


CHAPTER   IV. 

MALFORMATIONS   OF   THE    REPRODUCTIVE  ORGANS    OF 

WOMEN. 

MALFORMATIONS   OF   THE    VULVA. 

Hermaphrodism   and  Pseudo-hermaphrodism. — 

Hermaphrodism  implies  the  combination  in  an  individual  of 
functional  male  and  female  sexual  organs. 

Men  and  women  are  distinguished  from  each  other  by- 
two  sets  of  sexual  characters,  primary  and  secondary. 

Primary  Sexual  Characters. — These  are  directly  associated 
with  the  function  of  reproduction.  In  a  man  they  include 
the  penis,  the  testes  with  the  vasa  deferentia,  the  prostate, 
and  Cowper's  glands.  In  a  woman  they  consist  of  the 
vagina,  the  ovaries,  the  Fallopian  tubes,  and  the  uterus. 

Secondary  Sexual  CJiaracters. — These  comprise  those 
features  which  enable  the  male  to  be  distinguished  from  the 
female  irrespective  of  the  organs  of  reproduction  and  those 
used  for  the  nourishment  or  protection  of  the  young. 

The  characters  belonging  to  this  group,  so  far  as  the 
human  family  is  concerned,  are  exclusively  in  possession  of 
the  male.  Man  is  distinguished  from  woman  not  only  in 
the  possession  of  a  beard  and  greater  muscular  develop- 
ment with  its  necessary  accompaniment,  greater  physical 
strength,  but  he  has  a  more  powerful  voice,  and  the  skin  of 
his  trunk  and  limbs  is  thick  and  more  abundantly  supplied 
with  coarse  hair,  which  has  a  somewhat  different  disposition 
in  women.  In  man  the  front  of  the  chest  is  usually  covered 
with  hair,  and  that  on  the  pubes  passes  upward  to  the  um- 
4  -19 


50  D/SEAS/:S   OF   IVOA/E.y. 

bilicus,  whereas  in  the  female  it  is  restricted  to  the  mons 
Veneris.  A  less  constant  feature,  but  one  which  seems  con- 
fined to  men,  is  a  luxuriant  growth  of  hair  on  the  promi- 
nence of  the  pinna  known  as  the  tragus. 

Secondary  sexual  characters  are  not  present  in  the  young, 
but  become  manifest  at  puberty,  by  which  term  we  signify 
reproductive  maturity.  At  this  period  the  generative  or- 
gans increase  in  size,  and  in  the  male  become  functionally 
active.  In  the  female,  puberty  is  more  strikingly  declared 
by  the  institution  of  menstruation. 

Until  the  advent  of  puberty  the  boy,  so  far  as  secondary 
characters  are  concerned,  resembles  the  female  as  much  as 
he  does  the  male,  but  after  that  period  he  begins  to  assume 
those  indicative  of  the  male. 

It  occasionally  happens  that  children  are  born  with  mal- 
formed external  genital  organs  which  render  it  difficult  to 
determine  whether  the  child  is  male  or  female ;  even  when 
the  individual  attains  puberty  the  secondary  sexual  charac- 
ters appear  in  such  form  as  to  increase  rather  than  to 
diminish  the  doubts  which  were  entertained  at  the  child's 
nativity. 

When  doubt  exists  as  to  the  sex  of  a  child  it  is  often 
termed  an  hermaphrodite.  This  term  is  employed  by  natu- 
ralists to  signify  an  animal  possessing  conjoined  ovaries  and 
testes  (a  combination  occasionally  occurring  in  vertebrata 
and  known  as  an  ovotestis),  or  an  ovary  on  one  side  and  a 
testis  on  the  other.  There  is  no  example  on  record  of  such 
combinations  in  a  human  individual  which  survived  its 
birth,  but  individuals  to  which  the  term  hermaphrodite  is 
usually  applied  are  those  in  which  there  is  defective  devel- 
opment of  the  external  genitals  and  the  secondary'  sexual 
characters  resemble  those  of  the  female.  So  far  as  the 
human  family  is  concerned  individuals  with  malformed  ex- 
ternal genitals  should  be  called  pseudo-hennaphrodites. 
Before  proceeding  to  describe  the  leading  features  of  this 
condition    it  will  be   necessary  to  briefly  review  the  main 


MALFORMATIONS   OF  KKPRODUCI'lVE    ORGANS.        5  I 

facts  which  have  been  ascertained  in  reijard  to  the  develop- 
ment of  the  organs  of  reproduction. 

The  early  embryo  possesses  in  a  potential  form  the  pri- 
mary sexual  organs  of  both  sexes,  and  at  an  early  stage  in 
its  development  it  would  be  impossible  to  determine  its  sex 
(Fig.  11).    In  this  undifferentiated  stage  the  future  reproduc- 


Genital  gland. 
Mesonephros. 

Muller's  duct. 
Round  ligament. 

Ureter. 

Mesonephric  duct. 

Conjoint  Midler  s  ducts. 

Urethra. 

Orifice  of  Midler  s  duct. 

Uro-genital  sinus. 

Penis  ;  clitoris. 


Fig.  II. — Generative  organs  of  the  embryo  before  the  differentiation  of  sex  (Henle). 

tive  organs  are  represented  by  two  glandular  masses  which 
ultimately  become  the  genital  glands,  and  associated  with 
them  is  a  remarkable  temporary  organ  known  as  the  meso- 
nephros (Wolffian  body),  furnished  with  a  series  of  tubules 
— the  mesonephric  (Wolffian)  tubules,  opening  into  a  duct 
— the  mesonephric  (Wolffian)  duct,  which  terminates  in  a 
recess,  known  as  the  uro-genital  sinus,  which  opens  to  the 


52 


D/sEAS/:s  or  women. 


exterior.  In  ailtiilinn  to  the  ducts  just  mentioned  there  is 
another  pair,  known  as  Mi'iller's  ducts,  which  are  jieculiar 
inasmuch  as  they  open  into  the  ctelom  (pleuro-peritoneal 
cavity) ;  they  run  parallel  with  the  mcsoncphric  ducts  and 
open  into  the  uro-<;enital  sinus.  The  external  opening  of 
this  sinus  is  surmounted  anteriorly  by  a  va.scular  body 
and  laterally  is  limited  by  two  parallel  folds  of  skin. 

In  the  male  (Fig.  1 2)  the  genital  masses  become  testicles, 
the  mesonephric  (Wolffian)  tubules  and  ducts  develop  and 


Testis. 
-Epididymis. 


Vas  deferens. 
Ureter, 


Vesicula. 

Sinus  pocularis. 

Prostate. 
Urethra. 

Bulb. 


Scrotum 


Urachus. 


Corpus 

cavcrnosum. 

Corpus 

spongiosum. 


Glans  penis. 


Fig.  12.— Generative  organs  of  the  male  (Hcnlc). 


become  vasa  efferentia ;  the  main  duct  on  each  side  is  known 
as  the  vas  deferens,  which  ultimately  opens  in  the  floor  of 
the  urethra,   the   adjacent  parts   of  which   become    exces- 


MALFORMATIONS   OF  KE PRODUCTIVE    ORGANS.       53 

sivcly  developed  and  form  a  musculo-glandular  or^an,  the 
prostate.  Coincident  with  the  growth  of  the  mesonephric 
tubules  and  duct  the  glandular  part  of  the  mcsonephros 
atrophies,  and  its  vestiges  are  incorporated  with  the  testis 
and  lie  between  the  body  of  the  testis  and  its  globus 
major,  closely  associated  with  the  vasa  efferentia.  Usually 
the  Miilleriaii  ducts  atrophy  except  at  their  extremities,  the 
lower  of  which  fuse  to  form  a  sinus  in  relation  with  the 
prostatic  urethra — the  sinus  pocularis ;  the  anterior  ex- 
tremity being  probably  represented  by  a  pedunculated 
body,  the  cyst  of  Morgagni. 

In  the  female  (Fig.  13)  the  Miillerian  ducts  develop  and 
fuse  in  their  middle  and  posterior  thirds  to  form  a  median 
muscular  organ,  the  uterus  and  vagina ;  the  anterior  thirds 
remain  separate  as  the  Fallopian  tubes.  The  genital  masses 
become  ovaries ;  the  remains  of  the  mesonephros  and 
the  associated  tubules  and  duct  persist  as  vestiges.  The 
glandular  elements  of  the  mesonephros  are  known  in  the 
adult  ovary  as  the  paroophoron,  its  tubules  form  the  vertical 
tubes  of  the  parovarium,  and  the  duct  occasionally  persists 
throughout  its  whole  length  as  Gartner's  duct. 

It  has  already  been  pointed  out  that  the  orifice  of  the 
uro-genital  sinus  is  surmounted  by  a  small  eminence  and  is 
laterally  limited  by  cutaneous  folds.  In  early  embryonic 
life  this  orifice  is  common  to  the  terminations  of  the  urethra, 
genital  passages,  and  alimentary  canal.  Subsequently  the 
orifice  of  the  gut  is  separated  from  the  uro-genital  passage, 
the  posterior  orifice  becomes  the  anus  and  the  anterior  be- 
comes the  uro-genital  opening,  and  the  structures  in  its 
walls  specialize  into  labia  majora,  labia  minora,  clitoris,  and 
hymen,  w'ith  the  various  recesses  which  in  the  adult  receive 
special  names. 

In  the  male  further  fusion  and  development  take  place ; 
the  parts  which  in  the  female  persist  as  labia  fuse  together 
and  form  the  scrotum,  and  at  the  same  time  the  anterior 
prominence  enlarges    and  becomes  the    penis;    the  lateral 


54 


DISEASES   OJ-    WOMEN. 


folds  fuse  in  the  median  line  to  form  a  canal,  known  as  the 
membranous  and  penile  urethra,  alon^  its  lower  border. 
P^inally  the  testicles  descend  from  the  lumbar  region  into 
the  false  pelvis,  then,  preceded  by  a  pouch  of  peritoneum, 


Round  Ui^amcul 


Crura 
Bulbi  vestihuli 


Clitoris. 
Fig.  13. — Generative  organs  of  the  fcnialc  (Henic). 

traverse    the    abdominal   wall,  and    finally  occupy    perma- 
nently the  scrotum. 

Thus  a  .study  of  the  developmental  histoiy  of  the  genital 
organs  enables  us  to  prove  that  the  female  possesses  ves- 
tiges  of   male   organs,   whilst   the   chief    male   organs   are 


MALFORMATIONS   OF  REPRODUCTIVE    ORGANS.       55 

represented  in  the  female,  as  set  down   in  the  subjoined 
table : 

Adult  Male.  Adult  Female. 

Body  of  testis.  Oophoron. 

Faradidyniis.  Paroophoron. 

Vasa  efi'erentia.  Parovarium  (epoophoron). 

Vas  deferens.  Duct  of  Gartner. 

Fallopian  tube. 

Uterus. 

Sinus  pocularis.  Vagina. 

Corpora  cavernosa  (penis).  Corpora  cavernosa  (cliloridis). 

Corpus  spongiosum.  Glans  clitoridis  and  vestibular  bulbs. 

Prostatic  urethra.  Urethra. 

Membranous  urethra.  Vestibule. 

Folds  at  the  entrance  to  sinus  Hymen. 

pocularis. 

Cowper's  glands.  Bartholin's  glands. 

Scrotum.  Labia  majora. 

The  embryology  of  the  genitalia  makes  it  clear  so  far  as 
the  external  organs  are  concerned  that  the  male  organs  are 
more  highly  specialized  than  those  of  the  female,  and  if  the 
fusion  of  the  parts  concerned  in  forming  the  penile  urethra 
be  arrested,  a  condition  more  or  less  resembling  the  female 
is  the  consequence. 

For  example,  the  external  genitals  represented  in  Fig.  14 
illustrate  this  very  well.  The  erectile  body  is  really  an  in- 
complete penis,  the  penile  urethra  is  represented  by  a  groove 
opening  into  a  cul-de-sac  which  corresponds  to  an  incom- 
plete vulva.  The  two  halves  of  the  scrotum  have  failed  to 
unite  across  the  median  line,  and  thus  resemble  labia  majora. 
The  right  one  contains  a  testis ;  the  left  testis  was  retained 
in  the  inguinal  canal.  This  individual  was  a  hypospadiac 
male,  but  to  his  misfortune  was  brought  up  as  a  girl. 

Imperfections  of  this  kind  in  the  external  genital  organs 
are  associated  with  modifications  of  the  secondary  sexual 
characters.  The  distribution  of  hair  on  the  pubes  may  resem- 
ble the  female  type ;  often  it  corresponds  to  that  of  a  male. 
Menstruation  depends  on  the  co-existence  of  a  uterus  ;  of 


56 


DISEASES   OE   WOMEN. 


this  more  will  be  stated  later  on.  The  mamm.x'  may  be  as 
lar^a'  as  those  of  a  woman  ;  more  often  they  are  of  the  male 
type.  The  hair  on  the  heatl  is  no  guide,  for  if  an  indi- 
\itlual  has  been  trained  as  a  boy  it  is  short ;  if  a  girl  it  will 
usually  be  long.  The  presence  or  absence  of  hair  on  the 
face  varies.     A  pseudo-hermaphrodite  may  have  an  abun- 


Fio.  14. — The  external  genitals  of  a  hypospadiac  male  or  pseudo-licrniaphrodite. 


dant  beard  and  mustache.  At  puberty  the  voice  changes 
to  that  of  a  man  and  sexual  inclination  is  manifested  for 
women. 

It  is  a  significant  fact  that  the  condition  of  tiie  external 
genitals  in  pseudo-hermaphrodites  affords  no  reliable  indica- 
tion  of  the  nature  of  the  internal   ijcnital   orcfans.     An   in- 


MALFORMATIONS   OF  KFTIWDUCTIVF    ORGANS. 


57 


dividual  with  such  imperfections  as  are  presented  in  Fig.  15 
may  or  may  not  have  a  uterus  and  Fallopian  tubes.  On 
the  other  hand  a  uterus  may  be  associated  with  a  perfect 
penis  and  testes.  The  presence  of  a  uterus  does  not  enable 
us  to  decide  the  sex  in  a  doubtful  case.  In  questionable 
cases  of  sex  the  only  absolute  test  is  the  genital  glands. 
The  presence  of  ovaries  is  decisive  proof  of  a  female ;  testes 
indicate  the  male;  and,  as  accurate  discrimination  between 


Uterus. 


Fig.  15. — Sagittal  section  of  the  pelvic  organs  of  a  boy  with  a  well-developed  uterus  (Mu- 
seum of  Middlesex  Hospital). 

a  testis  and  an  ovary  is  only  possible  on  microscopic  exam- 
ination, it  is  only  in  exceptional  circumstances  that  such  a 
test  can  be  applied. 

It  is  impossible  in  an  elementary  work  of  this  kind  to 
describe  the  various  defects  of  the  reproductive  organs  which 
occur  in  pseudo-hermaphrodites,  but  in  the  majority  of 
these  unfortunate  individuals  the  genital  glands  are  testes, 
notwithstanding  the  fact  that  many  of  them  have  a  uterus 
with  Fallopian  tubes. 


5« 


DISEASES   OF   WOMEN. 


The  majority  of  pscudo-hcrniapliroditcs  arc  brought  up 
as  girls ;  this  is  a  iiiisfortiinc,  because  at  puberty  (which 
may  be  j^reatly  dehi)etl)  the  supposed  girl  suddenl}-  assumes 
the  voice  of  a  man  and  begins  to  grow  a  beard. 

\\' hen  there  is  doubt  as  to  the  sex  of  a  child  it  should  be 
named,  trained,  and  educated  as  a  boy. 

Exstrophy  of  the  bladder  has  sometimes  given  rise  to  dif- 
ficulty in  determining  the  sex  of  a  child  (Fig.  i6).     Careful 


Fig.  i6. — Exstrophy  of  the  bladder  in  a  girl  ^Museum  of  Middlesex  Hospital). 

examination  will  dispel  this  difficulty,  for  on  cleaning  the 
pink  vesical  mucous  membrane  exposed  at  the  pubes,  urine 
will  be  seen  to  escape  from  the  orifices  of  the  ureters. 


CHAPTER   V. 

MALFORMATIONS  OF    THE  REPRODUCTIVE   ORGANS    OF 

WOMEN   (Continued). 

MALFORMATIONS  OF  THE  VAGINA  AND 
UTERUS. 

Absence  of  the  Vagina. — This  may  occur  when  the 
uterus  also  is  absent ;  but  the  uterus  may  be  well  developed 
and  the  vagina  absent. 

Partial  Absence  of  the  Vagina. — This  is  more  com- 
mon, and  the  middle  part  is  most  often  deficient.  There  is 
then  a  short  sinus  opening  externally,  and  admitting  a  probe 
for  a  distance  of  perhaps  -g-  to  2  in.  (i  to  5  cm.) ;  the  cervix 
opens  into  a  closed  pouch,  the  remains  of  the  upper  end  of 
the  vagina.  A  solid,  cord-like  band  of  connective  tissue 
may  connect  the  two  portions  ;  less  often  the  lower  half  of 
the  vagina  is  absent.  In  some  cases  a  very  short  external 
sinus  is  present  and  the  rest  of  the  vagina  is  absent. 

Atresia  of  the  Vagina. — A  transverse  septum  may 
exist  at  any  part  of  the  vagina,  but  it  is  most  common  at 
the  vaginal  orifice.  This  condition  was  formerly  described 
as  atresia  of  the  hymen,  but  careful  examination  will  always 
discover  the  hymen  adherent  to  the  under  or  external  sur- 
face of  the  septum.  This  condition  is  due  to  the  lower  end 
of  the  fused  Mullerian  ducts  having  failed  to  open  into  the 
cloaca.  The  symptoms  and  treatment  of  these  conditions 
will  be  described  in  Chapter  VI. 

Narrowing  (Stenosis)  of  the  Vagina. — A  very  nar- 
row vagina  may  be  due  simply  to  partial  arrest  of  develop- 
ment;  in  other  cases  it  would  appear  that  one  Mullerian 
duct  has  failed  to  develop;  this  may  occur  with  a  normal 

69 


6o 


DISEASES   OF   WOMEN. 


uterus  or  in  association  with  a  uterus  of  whicli  only  one 
half  has  developed  (uterus  unicornis). 

The  trtitt))ic)il  is  dilatation  with  graduated  bougies. 

Double  Vagina. — This  is  always  associated  with  double 
uterus.  It  may  give  rise  to  no  symptoms,  even  after  mar- 
riage ;  but  the  longitudinal  septum  may  be  torn  through 
during  either  coitus  or  childbirth.  More  often  one  half  is 
enlarged  by  sexual  intercourse,  and  pregnancy  occurs  in 
the  corresponding  half  of  the  uterus. 

In  other  cases  one  half  only  is  completely  pervious,  the 
lower  portion  of  the  other  half  ending  blindly,  either  at  the 


ROUND    LIGAMENT 
UTERINE      HORN  \, 


Fig.  17. — Ritdimentary  uterus  (Schroeder). 


vulva  or  at  some  higher  point.  The  symptoms  may  then 
be  perplexing,  as  menstruation  may  seem  to  be  free  while 
the  occluded  portion  is  really  the  seat  of  ha,>matocolpos 
(Chap.  VI.).  As  in  the  case  of  a  single  vagina,  the  middle 
portion  only  of  one  half  may  be  obliterated  ;  its  lower  por- 
tion then  appears  as  a  sinus  opening  by  the  side  of  the 
larger  vagina. 

Tn'at))ic)it. — If  a  double  vagina  be  discovered,  the  sep- 
tum should  be  divided  throughout  its  whole  extent,  or, 
better  .still,  a  longitudinal  .strip  of  it  be  removed,  so  as  to 
throw  the  two  cavities  into  one.  This  will  minimize  the 
risk   of  complications  during  delivery.     The   vagina  must 


MALFORMATIONS   OF  REPRODUCTIVE    ORGANS.       6 1 


be  packxd  with  gauze  till  heal- 
ing has  taken  place,  to  pre- 
vent the  reunion  of  the  cut 
edges. 

Malformations  of  the 
Uterus. — Absence  of  the  ute- 
rus may  occur  with  or  without 
absence  of  the  ovaries. 

Rudimentary  Uterus. — 
The  uterus  may  be  present  in 
the  form  of  a  very  small  body 
with  rudimentary  horns  and 
Fallopian  tubes  (Fig.  17). 
From  incomplete  examination 
such  cases  have  been  erro- 
neously described  as  absence 
of  the  uterus.  The  ovaries 
are  small.  Important  other 
malformations  or  general  ar- 
rest of  development  usually 
co-exist.  But,  when  this  is 
the  only  malformation,  the 
secondary  sexual  characters 
appear  late,  or  not  at  all ;  and 
menstruation  is  absent. 

Infantile  Uterus.  —  The 
uterus  preserves  the  type 
which  it  presents  normally  at 
birth  ;  that  is  to  say,  the  whole 
organ  is  narrow  in  proportion 
to  its  length,  and  the  cervix 
is  long  in  proportion  to  the 
body.  The  external  os  is  small 
(pinhole  os)  and  the  cervix 
conical  (Fig.  18).  Acute  ante- 
flexion    frequently     co-exists. 


-The  conical  cervix  as  seen  in  a 
speculum  (A.  E.  G.). 


-A   normal    nulliparous    cervix 
(A.  E.  G.)- 


Fig.  20 


cervix  of  a  parous  woman 
(A.  E.  G. 


62  DISEASES    OE   WOMEN. 

This  may  be  associated  with  general  arrest  of  development 
of  the  genital  organs ;  or  the  otiier  parts  may  be  well 
formed.  Figs.  19  and  20  are  introduced  for  comparison 
with  the  conical  cervix. 

Syinptoiiis  niid  Sii^iis. — The  only  indication  of  the  condi- 
tion maybe  absence  of  menstruation  in  youth,  with  sterility 
later.  In  other  cases  scanty  and  painful  menstruation 
occurs. 

Bimanual  examination  shows  the  presence  of  a  small 
uterus,  probably  anteflexed.  If  a  sound  can  be  introduced 
through  the  narrow  external  os,  it  will  be  found  to  enter 
for  only  i^  or  2  in.  (3  to  5  cm.). 

Treatment. — In  the  absence  of  symptoms,  no  treatment 
should  be  attempted,  as  nothing,will  avail  to  induce  growth 
of  the  uterus  to  its  proper  size.  If  dysmenorrhcea  be  pres- 
ent, efforts  may  be  made  to  straighten  an  anteflexed  uterus 
and  to  render  its  canal  more  patulous  by  dilatation.  The 
sterility  is  incurable. 

Atresia  of  tlie  external  os  may  be  congenital  or  acquired. 
Both  are  rare.  Menstruation  may  be  entirely  absent,  and 
the  symptoms  and  signs  will  then  resemble  those  of  the 
infantile  uterus.  If  the  ovaries  and  the  body  of  the  uterus 
be  well  developed,  menstrual  molimina  will  occur,  with  the 
accumulation  of  menstrual  products  within  the  cavity  of  the 
uterus.     (See  Haematometra.) 

Single-homed  Uterus  {Uterus  unieornis). — If  one  half 
only  of  the  uterus  fail  to  develop,  this  condition  results  (Fig. 
21).  Both  ovaries  may  be  well  developed,  but  as  a  rule 
the  one  associated  with  the  rudimentaiy  cornu  retains  its  in- 
fantile shape.  The  vagina  is  often  narrow  and  the  uterine 
cavity  small.  Nevertheless,  no  symptoms  may  be  present 
and  the  woman  may  menstruate,  have  sexual  intercourse, 
and  become  pregnant,  just  as  in  the  normal  condition.  On 
the  other  hand,  if  pregnancy  occur  in  the  rudimentary  horn 
it  practically  takes  the  course  of  a  tubal  gestation,  resulting 
in  rupture. 


MALFORMATIONS   OF  KEPRODUCriVE    ORGANS. 


63 


Double  Uterus. — There  are  three  types  of  the  con- 
dition known  as  double  uterus,  viz.  the  uterus  septus,  the 
uterus  bicornis,  and  the  uterus  didelphys.  The  primary 
feature,  embryologically,  is  incomplete  union  of  Muller's 
ducts. 

I.  In  the  Uterus  septus  the  ducts  have  fused  exter- 
nally, but  the  septum  formed  by  their  approximation  per- 


Tube. 


Uterine  cornua. 


Tube. 


Fig.  21. — Uterus  unicornis. 


sists  ;  consequently  the  uterus  seen  from  the  outside  appears 
normal.  On  section  it  is  found  to  contain  two  distinct  cavi- 
ties. The  septum  may  extend  to  the  vulva,  producing  a 
vagina  with  the  appearance  of  a  double-barrelled  gun ;  or 
it  may  involve  the  uterus  alone,  the  vagina  being  single ;  or 
it  may  fail  to  reach  the  external  os,  in  which  case  the  cer- 
vix looks  normal  when  seen  through  a  speculum.  This  is 
the  titcrns  S7ibscptus. 

2.  In  the  uterus  bicornis  external  union  has  occurred 
in  the  lower  part  of  the  uterine  body,  but  is  wanting  in  the 
upper  part ;  so  that  when  such  a  case  is  bimanually  ex- 
amined, the  depression  between  the  two  halves  of  the 
fundus  is  plainly  felt  (Fig.  22).  Here  also  the  extent  of 
the  septum  varies,  reaching  to  the  vulva,  to  the  os  exter- 


64 


DISEASES   OE   WOMEN. 


luiin.  or  to  the  os  intcinuin   only.     The  last  kind  gives  the 
vaiict)-  known  as  uterus  hicornis  unicollis. 

3.  In  uterus  didelphys  (Fig.  23)  the  two  halves  of  the 
uterus  have  remained  externally  distinct,  and  can  be  moved 
independently  of  one  another.  The  vagina.-  are  invariably 
separate,  though  united  by  connective  tissue,  and  a  loose 


Fig.  22. — Uterus  bicornis  (Schroeder). 

bridge  of  connective  tissue  and  peritoneum  stretches  be- 
tween the  cervices.  A  well-marked  fold  of  peritoneum 
usually  stretches  directly  between  the  bladder  and  rectum, 
passing  between  the  two  halves  of  the  uterus. 

Each  uterus  has  its  own  Fallopian  tube,  whose  point  of 
junction  with  the  uterine  body  is  indicated  by  the  origin  of 
the  round  ligament ;  it  has  also  its  own  ovary. 

The  two  halves  are  often  unequally  developed,  and  one 
vagina  may  end  blindly  above  the  vulva,  so  that  the  corre- 
sponding uterus  is  quite  shut  off  from  the  outside. 

Diagnosis. — The  presence  of  tw^o  vaginal  canals  is  a  cer- 
tain indication  that  the  uterus  is  double.  Where  the  vagina 
is  single,  the  malformation  of  the  uterus  may  be  discovered 
in  one  of  several  \vays.  Thus,  when  the  division  involves 
the  cervix,  two  ora  externa  may  be  seen  through  the  specu- 
lum ;  on  bimanual  examination  two  separate  uterine  cornua 


MALFORMATIONS   OF  REPRODUCTfVE    ORGANS.       65 

may  be  felt,  with  a  depression  between.  The  condition  may 
be  suspected  from  the  passage  of  the  sound  in  two  different 
directions;  when  one  half  has  become  occkided,  with  reten- 
tion  of   menstrual   blood,   the  opening  of   tlie    fluctuating 


Fig.  23. — Uterus  didelphys. 


tumor  may  reveal  the  presence  of  the  second  canal ;   lastly, 
some  complication  during  delivery  may  lead  to  diagnosis. 

A  careful  examination  is  required  to  distinguish  the 
variety  of  double  uterus.  If  bimanually  the  fundus  feels 
normal  in  shape,  whilst  two  cervical  openings  are  present, 
and  two  sounds  can  be  simultaneously  introduced  without 
coming  in  contact  inside  the  uterus,  the  case  is  one  of 
uterus  septus.      If  a  well-marked  central  depressiDii  exists, 

5 


66  DISEASES    OE   WOMEN. 

wc  have  to  deal  with  uterus  bicornis  or  uterus  didelphys. 
If  the  cer\'ix  be  single,  it  is  a  two-horned  uterus.  If  it  be 
double,  the  following  points  will  serve  to  distinguish  the 
two.  In  the  case  of  the  uterus  bicornis,  the  two  halves  are 
closely  adherent,  usually  for  some  distance  above  the  level 
of  the  internal  os  ;  and  they  cannot  be  moved  independently. 
In  the  case  of  the  uterus  didelphys,  the  twc;  halves  can  be 
so  moved ;  indeed,  one  may  be  found  lying  in  front  of,  or  at 
some  distance  from  the  other;  and  further,  the  separation 
down  to  the  level  of  the  external  os  can  be  distinctly  felt 
by  recto-abdominal  examination. 

In  both  cases  the  points  of  two  sounds  simultaneously 
introduced  may  diverge  widely,  pointing  perhaps  to  the 
respective  iliac  crests,  while  the  handles  cross  each  other  in 
the  vagina  at  right  angles. 

As  a  rule,  each  horn  or  each  half-uterus  can  be  felt  to 
have  attached  to  it  its  own  Fallopian  tube  and  ovary. 

Coiiip/ications. — One  half  of  a  double  uterus  may  be  oc- 
cluded at  the  cei"vix ;  or  there  may  be  atresia  of  the  cor- 
responding vagina  ;  in  which  case  the  symptoms  of  haemato- 
metra  arise.  Otherwise  a  double  uterus  may  give  rise  to 
no  symptoms  at  all,  and  several  pregnancies  may  be  passed 
without  the  condition  being  suspected.  In  other  cases  some 
complication  arises  during  delivery,  leading  to  discovery  of 
the  condition  ;  but  considerable  perplexity  may  be  caused 
at  first.  Thus  in  some  cases  an  obstetrician  has  on  exam- 
ination found  a  wide  vagina  and  dilating  cervix ;  a  later 
examination,  in  which  the  finger  has  inadvertently  entered 
the  second  vagina,  has  revealed  a  narrow  vagina  and  a 
closed  OS.* 

The  following  are  the  clinical  complications  to  which  a 
double  uterus  may  give  rise: 

1.  Unilateral  atresia,  with  retained  menstrual  products. 

2.  Dyspareunia. 

'  For  a  summary  of  recorded  cases  of  uterus  didelphys  the  reader  is  referred 
to  the  Obstet.  Traits.,  vol.  xxxvii. 


MALFORMATIONS   OF  RFPRODUCTIVE    ORGANS.       6j 

3.  Double  vaginitis  or  endometritis,  treated  unsuccess- 
fully by  applications  to  one  side  only. 

4.  Obstruction  to  delivery  by  a  displaced  empty  half. 

5.  Obstruction  due  to  the  vaginal  septum. 

6.  Retained  and  undiscovered  products  of  conception  in 
one  half  in  cases  of  double  pregnancy. 

The  two  halves  of  a  double  uterus  may  menstruate  inde- 
pendently. When  pregnancy  occurs  in  one  half,  a  decidua 
forms  in  the  other  half 

Trcat))ic)it. — A  double  uterus  does  not  require  treatment 
as  a  rule ;  but  if  a  double  vagina  exists,  the  septum  should 
be  removed. 


CHAPTER   VI. 

RETENTION    OF    MENSTRUAL    PRODUCTS    IN    CASES    OF 

ATRESIA. 

According  to  the  situation  of  the  atresia  and  the  duration 
of  the  symptoms,  the  following  conditions  maybe  met  with, 
shown  diagrammatically  in  Figs.  24  and  25  : 

I.  Atresia  of  the  Vaginal  Orifice. — At  first  the  men- 
strual blood  collects  in  the  vagina,  which  becomes  distended 
(A)  and  often  bulges  through  the  vulvar  aperture — lucuiato- 
colpos.  Later,  the  cervix  distends  and  its  walls  are  thinned, 
the  body  of  the  uterus  not  being  at  first  affected  (j5) — 
Jiceniatotracluion.  By  continued  accumulation  the  body  of 
the  uterus  is  involved  {C) — hcematomctra.  Lastly,  the  Fal- 
lo})ian  tubes  may  become  distended  {D) — lucuiatosalp'uix. 

II.  Absence  of  the  I/Ower  or  Middle  Portion  of 
the  Vagina. — The  distention  occurs  in  the  same  order  as 
above,  first  the  vagina  {R)  and  then  the  uterus  {F^  being 
affected.  The  lower  portion  of  the  vagina,  if  present,  is 
patulous. 

III.  Atresia  of  the  Os  Externum. — The  vagina  re- 
mains normal,  and  htematotrachclos  first  occurs  {G).  It  is 
probable  that  considerable  distention  may  take  place  here 
without  the  body  of  the  uterus  sharing  in  it.  Later, 
h;ematometra  and  ha:matosalpinx   ma)'  follow. 

IV.  Atresia  of  the  Os  Internum. — The  cervi.x,  as 
well  as  the  vagina,  remains  free,  and  a  pure  hajmatometra 
is  found  (//).     As  a  congenital   condition,  this  is   rare. 

V.  Atresia  affecting  One  Half  of  a  Double  Uterus 
or  Vagina. — Changes  occur  in  the  same  order  as  in  the 

08 


MENSTRUAL   rRODUCTS  IN  ATRESIA. 


69 


case  of  the  undivided  organs ;  when  the  atresia  concerns 
the  second  vagina,  hieniatocolpos  is  first  found,  the  cystic 
swelling  extending  either  down  to  the  vulva  (/)  or  only 
part  of  the  way,  by  the  side  of  the  patent  vagina  (/). 
Haimatometra  follows  (A'),  or  it  occurs  alone  if  the  atresia 


D  E  F 

Fig.  24. — Diagram  illustrating  the  effects  of  atresia  of  the  genital  passages  (A.  E.  G.). 

affects  the  os  externum  {L).     In  the  diagram  the  various 

forms  of  atresia  in  cases  of  double  uterus  are  represented 

as    affecting   the    uterus    bicornis ;    but    similar    conditions 

are   found    in    connection   with   uterus    septus    and    uterus 

didelpln's. 

.    Secondary   Changes. — The    dilated   walls    of  the  vagina, 


70 


DISEASES   OE   WOMEN. 


uterus,  or  r^illopian  tubes  become  thinned  out;  the  contrast 
between  health)-  and  distended  walls  is  well  seen  in  the 
uterus  itself,  where  the  endometrium  suffers  considerable 
atrophy,  and  the  muscular  coat  is  thinned.     This  thinning 


/  A-  /- 

Fir..  25. — Diagram  illustrating  the  eflfccts  of  atresia  of  the  genital  passages  (A.  E.  G.)- 

may  be  partly  compensated,  as  in  the  case  of  an  aneuiysm, 
by  the  deposition  of  blood-clot  on  the  internal  surface,  and 
partial  organization  of  the  fibrin. 

Suppuration  may  take  place,  either  spontancousl}-  or 
through  a  temporary  fistulous  ajK-rture.  When  the  atresia 
is  secondar}',  this  result  is  more  common.  The  vagina, 
uterus,  or  Fallopian  tubes  may  then  become  bags  of  pus, 


MENSTRUAL    rRODUCTS  IN  ATRESIA.  7  I 

and  the  terms  pyocolpos,  pyometra,  and  pyosalpinx  are 
applied. 

Signs  and  Symptoms. — The  first  symptoms  generally 
occur  within  the  first  year  or  two  after  puberty.  The 
patient  gives  a  history  of  having  experienced  periodical 
monthly  molimina  without  external  menstruation  {crypto- 
mcnorrJuvii).  Pain  is  sometimes  felt  from  the  first ;  in  other 
cases  it  occurs  later,  and  increases  in  severity  and  duration 
as  distention  proceeds,  till  it  becomes  continuous.  Symp- 
toms of  pressure  on  surrounding  organs  may  also  be  pres- 
ent. If  suppuration  takes  place,  febrile  symptoms  appear 
and  the  patient  falls  into  a  hectic  condition. 

Physical  Signs. — On  abdominal  palpation  a  tense  fluctu- 
ating swelling  may  often  be  felt  rising  out  of  the  pelvis ; 
and  if  the  obstruction  be  at  the  vulva  it  may  be  seen  bulging 
here  also.  Fluctuation  may  be  obtained  on  pressing  alter- 
nately on  the  abdominal  and  vulvar  swellings.  When  the 
uterus  itself  is  not  involved,  it  may  sometimes  be  felt 
through  the  abdomen  as  a  solid  projection  at  the  summit 
of  the  cystic  swelling. 

We  will  consider  in  succession  the  physical  signs  afforded 
by  the  different  conditions  above  enumerated. 

Atresia  of  the  Vaginal  Orifice. — The  finger  at  once  meets 
the  resistance  of  the  cystic  swelling  at  the  vulva,  and  no 
passage  exists  by  the  side  of  it.  By  combined  rectal  and 
abdominal  examination  it  can  be  felt  that  the  mass  fills 
the  pelvis ;  if  seen  early  the  fingers  may  meet  above  the 
swelling,  or  the  undilated  uterus  can  be  made  out.  If 
hsematometra  also  exists,  the  swelling  is  larger;  but  the 
degree  to  which  the  uterus  is  involved  cannot  usually  be 
determined  till  the  retained  fluid  has  been  evacuated.  An 
irregularity  of  the  summit  of  the  swelling  can  often  be  felt 
by  the  abdomen  when  the  Fallopian  tubes  are  distended  ; 
but  this  is  not  always  the  case  because  the  tubes  are  apt  to 
be  drawn  into  a  position  parallel  with  the  uterus,  just  as 
when  the  uterus  is  enlarged  by  pregnancy  or  a  myoma. 


72  DISEASES   OE   WOMEN. 

Absence  of  the  Lcncer  or  Middle  Part  of  the  Vagi>ia. — 
The  short  cul-dc-sac,  wlicn  it  exists,  is  patent  for  2  or 
5  cm.,  but  nothing  further  can  be  made  out  by  the  va- 
gina. On  examining  by  the  rectum,  the  finger  will  read- 
ily recognize  a  sound  introduced  through  the  urethra, 
there  being  but  little  tissue  intervening.  But,  higher  up, 
the  finger  meets  the  resistance  of  a  cystic  swelling,  con- 
tinuous with  a  similar  swelling  felt  by  the  abdomen  when 
the  distention  is  considerable.  If  the  vaginal  deficiency 
extends  to  near  the  uterus,  it  may  not  be  possible  to  reach 
the  hxMnatocolpos  through  the  rectum ;  and  an  ill-defined 
abdominal  fulness  may  be  the  only  thing  felt.  But  this, 
taken  in  conjunction  with  the  history  and  symptoms,  may 
serve  for  diagnosis. 

Atresia  of  tlie  Os  Externum. — The  cervix  presents  in  the 
otherwise  normal  vagina,  as  a  smooth  fluctuating  swell- 
ing in  which  no  aperture  can  be  discovered.  Bimanu- 
ally  the  mass  is  felt  to  occupy  the  position  of  an  enlarged 
uterus.  The  fundus  may  be  felt  as  a  smaller  and  harder 
projection  at  the  summit  of  the  elastic  swelling. 

Atresia  of  the  Os  Liternnni. — The  cervix  feels  and  ap- 
pears normal ;  the  body  of  the  uterus  is  uniformly  en- 
larged, and  feels  almost  exactly  like  a  pregnant  uterus. 

Atresia  of  One  Half  of  a  Double  Uterus  or  ]\igi)ia. — 
The  patent  half  of  the  vagina  is  narrow,  but  other- 
wise resembles  the  normal.  The  uterus  appears  to  be 
pushed  over  to  one  side,  and  the  sound  passes  in  a  lat- 
eral direction  for  a  normal  distance.  On  one  side  of  the 
vagina  is  felt  a  fluctuating  swelling,  extending  down  to 
the  vulva,  or  reaching  only  part  of  the  way.  It  bulges 
toward  the  healthy  side  so  as  to  further  narrow  the  va- 
ginal passage.  By  bimanual  examination  the  swelling  is 
felt  to  extend  up  to  the  side  of  the  uterus,  with  which  it 
is  closely  connected.  When  the  vagina  is  undivided,  and 
the  atresia  is  situated  at  the  external  os  of  the  second 
uterus,  the  upper  part  of  the  vagina  is  very  wide.     At  one 


MENSTRUAL    PRODUCTS   LV  ATRESIA.  73 

side  is  the  cervix,  through  which  a  sound  can  be  passed 
into  the  uterus,  when  it  takes  a  lateral  direction.  The  rest 
of  the  vaginal  summit  is  occupied  by  a  cystic  swelling 
lying  to  the  side  of  the  uterus  and  cervix,  which  it  has  dis- 
placed beyond  the  median  line.  The  depression  between 
the  distended  and  the  empty  half  of  the  uterus  may  be  felt 
by  abdominal  palpation  or  by  the  bimanual  method. 

Diagnosis. — A  hzematocolpos  is  usually  readily  diag- 
nosed by  the  signs  and  symptoms  above  mentioned. 

H?Ematometra  must  be  diagnosed  from  pregnancy :  the 
integrity  of  the  hymen,  the  absence  of  vaginal  pulsation 
and  discoloration,  and  of  the  symptoms  of  pregnancy  will 
serve  as  a  guide,  as  will  also  the  condition  of  the  cervix, 
which  is  elastic  and  smooth  in  the  case  of  haematotrachelos^ 
and  which  does  not  present  the  softness  characteristic  of 
pregnancy,  when  the  obstruction  is  at  the  internal  os.  In 
cases  of  doubt  the  patient  may  be  kept  under  observation 
for  some  time ;  the  swelling  will  increase,  but  not  nearly  so 
quickly  as  is  the  case  in  pregnancy.  Haematotrachelos 
might  be  simulated  also  by  a  cyst  in  the  upper  part  of  the 
vagina  ;  careful  examination  will  discover  the  cervix  beyond 
the  cyst  in  this  case.  Other  conditions  which  superficially 
resemble  haematometra,  such  as  inversion  of  the  uterus  or 
a  large  cervical  polypus  lying  in  the  vagina,  do  not  occur  at 
the  age  at  which  haematometra  is  met  with ;  and  there 
should  be  no  difficulty  in  the  diagnosis. 

Retention  of  menses  in  a  second  vagina  or  uterus  leads 
to  much  greater  difficulty  in  diagnosis.  Thus,  haematocol- 
pos  must  be  distinguished  from  abscess  in  the  vaginal  wall, 
pelvic  abscess  burrowing  down  by  the  side  of  the  vagina, 
vaginal  cysts,  encysted  collections  of  fluid  bulging  down  in 
the  recto-vaginal  pouch,  and,  when  the  upper  part  of  the 
vagina  is  principally  involved,  from  ovarian  or  parovarian 
cysts  and  distended  tubes.  The  latter  would  be  recognized, 
principally  by  their  shape,  on  recto-abdominal  examination. 
The  nature  of  lower  vaginal  swellings  will  probably  not  be 


74  DISEASES   OF   WOMEN. 

made  out  till  they  arc  incised  ;  whilst  in  the  case  of  swellings 
lii^her  up,  the  abdomen  will  most  likely  be  opened,  under 
the  impression  that  the  case  is  one  of  ovarian  cyst. 

ll^ematometra  in  a  second  uterus  is  often  diagnosed  as 
ovarian  or  tubal  cystic  disease,  or  as  a  dermoid.  The  only 
clue,  in  the  absence  of  all  trace  of  a  second  cervix  or  of  a 
double  vagina,  lies  in  the  close  connection  of  the  swelling 
with  the  uterus ;  but  even  this  distinction  may  not  be  ap- 
parent, as  the  depression  in  the  fundus  in  the  case  of  uterus 
bicornis,  or  the  almost  complete  separation  of  the  two 
halves  in  the  case  of  uterus  didelphys,  gives  the  impression 
that  the  swelling  is  extra-uterine.  As  a  matter  of  fact,  the 
nature  of  the  case  is  rarely  recognized  until  the  abdomen 
has  been  opened  in  the  operating  theatre  or  the  post- 
morteni  room. 

Results. — If  left  untreated,  the  fluid  gradually  accumu- 
lates, the  size  of  the  swelling  causing  great  discomfort  as 
well  as  severe  pain.  Two  grave  complications  threaten : 
suppuration  may  take  place  and  a  large  abscess  form,  which 
opens  into  the  rectum  or  the  ccelom  (peritoneal  cavity)  or 
points  externally ;  or  rupture  of  some  part  of  the  sac  occurs. 
The  dilated  tubes  are  most  likely  to  give  way,  as  in  them 
the  greatest  thinning  ,of  the  walls  takes  place.  From 
either  complication  death  may  result.  It  is  important  to 
remember  that  a  haematocolpos  or  hasmatotrachelos  exer- 
cises  injurious  pressure  on  the  ureters. 

Treatment. — A  haematocolpos  must  be  opened.  The  in- 
cision should  be  free,  and  the  contents  allowed  to  escape 
without  any  pressure.  By  too  rapid  evacuation,  rupture  of 
a  ha^matosalpinx  may  be  brought  about ;  but  the  danger  of 
this  has  probably  been  exaggerated.  A  more  serious  risk 
is  that  of  septiccTemia ;  on  this  account  the  strictest  asepsis 
should  be  adopted.  When  the  greater  jxirt  of  the  fluid  has 
been  evacuated,  gentle  irrigation  may  be  employed  to  clear 
out  the  residue  and  prevent  decomiiosition  changes  from 
taking  place.     The  principal  difficulty  in  after-treatment  lies 


MENSTRUAL    PRODUCTS  IN  ATRESIA.  75 

in  the  tendency  of  the  orifice  to  contract ;  for  this  reason 
the  incision  must  be  free,  and,  if  necessary,  a  part  of  the 
wall  should  be  dissected  out.  The  passage  of  bougies  may 
be  subsequently  required  from  time  to  time. 

The  treatment  of  atresia  with  absence  of  a  part  of  the 
vagina,  is  more  difficult.  An  attempt  should  be  made  to 
dissect  down  to  the  deeper  part  of  the  vagina,  so  as  to 
make  a  complete  vagina ;  this  is  especially  necessary  in 
cases  of  retention.  The  first  difficulty  is  in  the  actual  dis- 
section, which  must  be  made  between  the  urethra  in  front 
and  the  rectum  behind :  a  distance  of  many  centimetres 
may  be  traversed  before  the  blind  end  of  the  vagina  is 
reached.  The  second,  and  perhaps  greater,  difficulty  is  to 
maintain  the  patency  of  the  vagina  when  formed.  With 
this  end  in  view  various  plastic  operations  have  been 
devised,  portions  of  skin  being  turned  in.  Repeated  ope- 
rations, extending  over  many  months,  have  sometimes  been 
required ;  but  several  ultimately  successful  cases  have  been 
reported. 

Haematometra  also  requires  incision.  Sometimes  the 
obstructing  membrane  is  so  thin  that  a  probe  or  sound  can 
readily  be  pushed  through  it ;  in  other  cases  a  knife  is  re- 
quired. After  incision,  forceps  should  be  introduced  to 
secure  a  free  aperture,  and  after  evacuation  the  cervical 
canal  is  loosely  packed  with  iodoform  gauze ;  whilst  later 
the  tendency  to  contract  must  be  met  by  the  use  of 
dilators. 

When,  in  case  of  haematometra  with  deficiency  of  the  va- 
gina, it  is  found  impossible  to  maintain  the  new  channel  in 
a  sufficiently  patulous  condition,  or  when  the  formation  of 
such  a  channel  is  not  practicable,  it  will  be  necessary  to 
carry  out  radical  measures,  such  as  o6phorectom\"  or 
hysterectomy. 

Lateral  lusmatocolpos  must  be  treated  on  the  same  prin- 
ciples as  the  above,  but  the  vaginal  septum  should  be  freel)' 
removed,  so    as  to  make    only  one  vagina,  otherwise  the 


jG  DISEASES   OF   WOMEN. 

oi)cnin<^f  will  almost  certainly  close  again,  and,  having  once 
been  opened,  septic  organisms  may  find  their  way  in,  and  a 
pyocolpos  be  found  the  next  time  instead  of  a  ha.'niato- 
colpos.     Of  this  there  are  several  instances  on  record. 

In  the  case  of  lateral  haimatometra,  vaginal  incision 
should  be  practised  when  possible,  and  part  of  the  uterine 
septum  may  be  removed,  to  prevent  re-closure.  If  the  con- 
dition be  discovered  after  opening  the  abdomen,  vaginal 
incision  should  still  be  perfocmed  when  the  two  halves  of 
the  uterus  are  closely  connected ;  although,  if  at  the  same 
time  there  be  vaginal  deficiency,  hysterectomy  will  probably 
be  called  for. 

In  cases  of  separation  of  the  two  halves  of  the  uterus,  as 
in  marked  instances  of  uterus  bicornis  or  uterus  didelphys, 
the  occluded  half  may  be  removed  by  hysterectomy. 
There  are  several  cases  recorded  in  which  this  was  done, 

Hajmatosalpinx  calls  for  removal  of  the  distended  tube. 

Characters  of  Retained  Menstrual  Blood. — The 
evacuated  fluid  is  a  dark  chocolate  color,  sometimes  almost 
black.  It  is  thick  and  flows  slowly,  like  treacle  or  honey. 
It  is  mixed  with  mucus  and  seldom  contains  coagula. 
Microscopical  examination  shows  the  presence  of  epithelial 
debris,  and  blood-corpuscles  in  various  stages  of  disintegra- 
tion. The  viscidity  is  due  to  partial  absorption  of  the 
liquid  portion  of  the  blood. 


CHAPTER   VII. 

DISEASES  OF  THE  VULVA. 

AGE-CHANGES;    INJURIES;    VARIX ;     HJEMA- 
TOMA;    INFLAMMATION. 

Age-changes.  —  Infancy.  —  At    this   period   the   mons 
Veneris  is  devoid  of  conspicuous  hair  and  the  labia  majora 


Prepuce. 
Clitoris. 

Frcnum. 
Nympha. 


Urethra. 


Orifice  of  vagina. 
Hymen. 


Fig.  26. — The  vulva  of  a  girl  (Henle) 

appear  as  two  parallel  cutaneous  eminences  ;  the  thin  edges 
of  the  labia  minora  project  between  them  and  arc  pink  like 
mucous  membrane  (Fig.  26). 

Puberty. — At  this  stage  the  pubic  hair  becomes  conspicu- 

77 


78 


DISEASES   OE   WOMEN. 


ous  and  usually  ^rows  freely  on  the  outer  surfaces  of  the 
greater  labia.  The  labia  increase  in  size  and  usually  con- 
ceal the  nj'niphiu.  Their  opposed  or  internal  surfaces  remain 
pink,  whilst  the  outer  surfaces  become  pigmented,  especially 
in  brunettes. 

It  occasionally  happens  that  the  nymplue  grow  after 
puberty,  and  instead  of  remaining  concealed  within  the  vul- 

v^ar  cleft,  protrude  and 
^  '  resemble  a  pair  of  elon- 

gated molluscan  palps. 
When  the  nymphac 
l)rotrude  in  this  way 
they  undergo  a  curious 
change :  those  parts  cov- 
ered by  the  labia  ma- 
jora  retain  their  pink- 
ness  and  possess  as 
usual  very  large  seba- 
ceous glands,  but  the 
palp-like  portions  be- 
come decph'  pigmented, 
lose  their  sebaceous 
glands,  and  occasionally 
delicate  hairs  of  two 
or  more  centimetres  in 
length  grow  from  them. 
Labia  minora  elongated 
in  this  way  are  some- 
times spoken  of  as  "  hypertrophied  nympha; ;  "  some  writers 
attribute  the  condition  to  masturbation.  It  reaches  its 
maximum  in  Hottentot  women,  whose  "  apron  "  is  really 
formed  of  greatly  elongated  nymphae  (Fig.  27). 

Menopause. — After  the  forty-fifth  year  the  hair  on  the 
mons  and  labia,  like  that  on  the  rest  of  the  bod}-,  becomes 
white  and  is  gradually  shed.  The  greater  labia  shrink  as  the 
subcutaneous  fat  disappears   and  the  n}'mph;e  project  bc- 


FlG.    27.- 


-The    Hfittentot   .ipron    (Blancbard   aiiJ 
Lcsutur). 


DISEASES   OF   THE    VULVA.  79 

yond  them.  The  vulvar  orifice  is  often  greatly  narrowed 
in  consequence  of  the  shrinking  of  the  structures  border- 
ing upon  it. 

Injuries. — The  vulva  is  liable  to  injury  from  falls  upon 
pointed  objects ;  cuts  from  potsherds  when  chamber-pots 
break  whilst  women  sit  upon  them ;  kicks  from  brutal  hus- 
bands ;  and  violence  during  rape.  The  labia  are  sometimes 
lacerated  during  the  careless  use  of  midwifery  forceps. 
Deep  wounds  of  the  vulva  are  invariably  attended  with  free 
bleeding. 

Treatment. — Turn  out  the  clots,  secure  the  bleeding 
points  with  forceps  and  ligature;  oozing  may  require  re- 
straint with  firm  pads  and  pressure. 

Varix. — The  vulva  is  well  supplied  with  veins,  and  con- 
tains especially  a  good  deal  of  erectile  tissue.  Obstruction 
to  the  venous  circulation  in  the  pelvis,  abdomen,  or  thorax 
consequently  readily  causes  the  veins  to  assume  a  varicose 
condition.  This  is  found  very  often  during  the  later  months 
of  pregnancy ;  and  in  some  cases  the  enlargement  may  be 
extreme,  forming  a  swelling,  on  one  or  both  sides,  as  large  as 
a  fist,  involving  principally  the  labia  majora,  and  presenting 
to  the  touch  the  characteristic  feeling  of  "  worms  in  a  bag," 
which  is  met  with  in  varicocele  of  the  scrotum.  The  left 
side  is  more  often  affected  than  the  right.  The  dilated  and 
tortuous  veins  can  also  be  readily  seen  through  the  skin. 
The  veins  of  the  thigh  are  generally  also  involved ;  and  on 
inspecting  the  vagina,  similar  venous  plexuses  may  be  seen, 
extending  up  a  considerable  distance  under  the  mucous 
membrane.  There  is  a  great  risk  of  rupture  of  these  veins 
during  delivery;  either  the  surface  veins  may  give  way, 
giving  rise  to  serious  bleeding,  or  subcutaneous  rupture 
may  occur,  producing  a  hjematoma  of  the  vulva. 

Treatment. — Rest  in  the  horizontal  position  diminishes  the 
swelling;  but  when  associated  with  pregnancy,  no  cure  can 
be  hoped  for  till  after  delivery.  In  severe  cases  it  may  be 
advisable  to  induce  premature  delivery,  to  diminish  its  se- 


8o  DISEASES   OF   WOMEN. 

verity  and  duration,  and,  through  the  smaller  size  of  the 
child's  head,  lessen  the  risk  of  rupture  and  thrombosis. 
When  due  to  other  varieties  of  backward  pressure  on  the 
veins,  the  cause  must  be  treated. 

Slight  cases  are  often  associated  with  chronic  constipa- 
tion, and  in  these,  as  well  as  in  severer  cases,  great  im- 
provement results  from  attention  to  the  bowels.  Excision 
of  the  veins  gives  good  results. 

Haematoma  of  the  Vulva. — This  is  due  to  subcu- 
taneous rupture  of  veins  in  the  labia  majora,  and  is  nearly 
always  traumatic.  A  fall  or  blow  may  cause  it,  but  it  gen- 
erally follows  delivery,  especially  when  the  child's  head  is 
large  and  has  rested  long  on  the  perineum. 

The  condition  is  usually  easily  recognized  from  the  his- 
tory, and  from  the  presence  of  a  smooth,  fluctuating  swell- 
ing in  the  labium  majus,  which  has  formed  quickly  and  is 
irreducible.  These  points  serve  to  distinguish  it  from 
hernia,  and  from  abscess  and  cyst  of  the  labium.  It  may 
not  be  easy  to  distinguish  it  from  simple  oedema ;  but  this 
is  unimportant,  as  the  treatment  is  the  same. 

Treatment. — On  no  account  should  a  haematoma  be 
opened,  unless  it  is  enlarging  quickly,  when  there  is  prob- 
ably a  large  vessel  ruptured ;  in  this  case  a  free  incision 
should  be  made,  the  clots  turned  out,  and  the  bleeding- 
point  secured.  Otherwise  the  extravasated  blood  tends  to 
absorb  readily,  and  generally  subsides  in  two  or  three 
weeks. 

Occasionally  a  hrcmatoma  suppurates  and  requires  free 
incision,  drainage,  and  strict  cleanliness. 

INFLAMMATION  OF  THE  VULVA. 

Vulvitis. — This  may  arise  from  many  causes.  In  girls 
it  is  often  due  to  dirt,  thread-worms,  and  tuberculosis  of 
the  uterus.  The  same  causes  may  produce  vulvitis  in  adult 
women.     Other  causes  are  vaginitis  resulting  from  gonor- 


DISEASES   OF  THE    VULVA.  Si 

rlioea,  and  extension  of  inflaniniation  from  surroundini:^  struc- 
tures.    Vulvitis  is  not  uncommon  in  the  newly  married. 

Signs  and  Syjnptoms. — The  patient  complains  of  throb- 
bing pain  and  heat  in  the  vulva,  aggj'avated  by  walking  and 
by  long  sitting ;  generally  also  of  discharge.  When  se- 
vere there  are  constitutional  febrile  symptoms.  When  the 
urethra  is  affected  there  is  burning  pain  on  micturition. 

The  vulva  is  congested  and  consequently  swollen.  The 
swelling  may  affect  individual  parts,  as  the  labia  majora, 
nymphai,  or  clitoris ;  or  the  whole  vulva  may  be  involved. 
It  may  be  bathed  in  discharge  from  the  vagina,  which 
may  be  mucous,  muco-purulent,  or  purulent ;  in  gonorrheal 
cases  it  is  always  purulent.  As  the  result  of  these  irri- 
tating discharges  the  skin  is  often  excoriated,  not  only 
over  the  vulva,  but  also  over  the  contiguous  part  of  the 
thighs  and  round  the  anus.  When  due  to  injury,  bruising 
and  ecchymoses  may  be  seen.  On  the  other  hand,  when 
of  gonorrhoea!  origin,  two  rather  characteristic  signs  are 
present:  firstly,  urethritis ;  the  meatus  is  red  and  swollen, 
and  on  pressing  on  the  urethra  through  the  vagina,  from 
within  outward,  a  drop  of  pus  commonly  escapes.  Sec- 
ondly, affection  of  the  ducts  of  the  Bartholinian  glands ;  in 
this  case  the  orifices  of  the  ducts  can  be  readily  seen  as  red 
points  situated  laterally  in  the  angle  between  the  h)^men 
and  labia  minora ;  on  pressing  the  duct  between  the  finger 
in  the  vagina  and  the  thumb  outside,  a  drop  of  pus  may 
escape ;  or  a  definite  swelling,  due  to  abscess,  may  be  pres- 
ent in  the  situation  of  the  duct  (see  Abscess  of  the  Vulva). 

The  lymphatics  of  the  vulva  pass  to  the  horizontal  set 
of  inguinal  glands  ;  these  will  therefore  be  enlarged  and 
tender  in  cases  of  severe  vulvitis. 

Diagnosis. — There  is  no  difficulty  in  recognizing  vulvitis, 
but  the  diagnosis  of  its  nature  is  often  as  difficult  as  it  is 
important.  The  question  is  whether,  in  a  given  case,  the 
condition  is  gonorrhoeal  or  not.  On  the  answer  much 
often  depends,  such  as  questions  of  criminal  assault  and  of 
6 


1 


82  DISEASES   OE   WOMEN. 

uncliastity.  If  the  ^onococcus  be  found  in  the  pus,  the  ex- 
istence of  gonorrhte.i  is  established  ;  its  absence,  however, 
is  no  proof  to  the  contrary.  If  the  inflammation  be  non- 
purulent, if  the  urethra  be  unaffected,  and  if  the  Bifttholin- 
ian  ducts  be  not  involved,  the  probability  is  strong  tliat  the 
case  is  not  gonorrhceal ;  in  the  opposite  conditions  the 
probability  is  in  favor  of  <^onorrhcea.  Some  information 
may  be  derived  from  the  existence  of  uretliritis  in  the  hus- 
band ;  if  he  have  a  marked  purulent  urethritis  and  the  pus 
contains  gonococci  the  ari^ument  is  in  favor  of  t^onorrhcea 
in  the  woman.  In  children,  want  of  cleanliness  and  tuber- 
culosis will  serve  as  a  clue;  but  it  must  be  remembered 
that  gonorrhoea  is  a  possible  condition  even  when  there  is 
no  suspicion  of  criminal  assault.  Some  epidemics  of  vulvo- 
vaginitis in  little  girls  have  been  of  this  nature  ;  and  the 
source  of  contagion  has  sometimes  been  traced  to  bad 
social  conditions,  such  as  the  fact  that  a  child,  sleeping  in 
the  same  bed  as  a  father  or  mother  suffering  from  gonor- 
rhoea, has  become  contaminated. 

Cojirsc  and  Coniplicatiivis. — A  simple  vulvitis  runs  a  short 
course  to  recovery,  under  proper  treatment.  If  neglected, 
or  if  septic  from  the  first,  the  possible  complications  are 
urethritis,  labial  absces.^,  cedema  and  gangrene  of  the  labia, 
infection  and  abscess  of  Bartholin's  glands,  inguinal  bubo, 
vaginitis,  endometritis,  salpingitis,  and  peritonitis. 

Treatment. — Tiie  patient  should  be  kept  in  bed  if  possible: 
if  there  be  constitutional  di.sturbance,  this  is  essential.  The 
parts  must  be  kept  thoroughly  clean  ;  a  warm  sitz-bath, 
medicated  with  boracic  acid,  carbolic  (i  :  60),  or  biniodide 
of  mercury  (i  :  2000),  and  repeated  several  times  a  day, 
will  ensure  cleanliness  and  relieve  pain.  After  a  bath  or 
irrigation  the  vulva  should  be  well  dried  and  dusted  with 
oxide  of  zinc,  and  a  pad  of  cotton-wool  applied.  If  there 
be  suppuration  on  the  surface,  all  discharge  should  be  re- 
moved by  irrigation,  and  the  surface  swabbed  over  with 
nitrate-of-silver  solution  (2  per  cent.),  chloride  of  zinc  (5  per 


DISEASES   OF   THE    VULVA.  83 

cent.),  or  carbolic  (10  per  cent,  in  glycerin).  Fomentations 
\vrun<^  out  of  boracic  acid  may  then  be  applied.  When  the 
inflammation  is  severe,  the  patient  should  lie  with  the  knees 
supported  on  a  pillow  and  separated  to  prevent  the  contact 
of  the  tender  surfaces. 

(Bdetna  of  the  Vulva. — This  may  occur  as  the  result 
of  vulvitis,  and  is  then  commonly  due  to  spreading  of  the 
inflammatory  process  to  the  deeper  tissues,  involving  vessels 
and  lymphatics.  More  often  it  depends  upon  pressure  on 
the  pelvic  veins,  by  tumors,  pelvic  inflammation,  or  the 
pregnant  uterus.  It  may  also  form  part  of  a  general 
anasarca  the  consequence  of  cardiac  or  renal  disease.  All 
parts  of  the  vulva  are  affected,  but  the  principal  enlarge- 
ment is  of  the  labia  majora.  The  whole  vulva  may  attain 
the  size  of  a  foetal  head. 

The  treatment  consists  in  rest  in  bed,  moderate  purgation 
and  warm  fomentations,  if  due  to  phlebitis  and  lymphatic 
obstruction.  When  due  to  pressure,  the  cause  must  if  pos- 
sible be  dealt  with — e.  g.  a  tumor  should  be  removed  ;  pel- 
vic inflammation  should  be  treated  as  described  under  that 
heading ;  pregnancy  may  occasionally  require  to  be  pre- 
maturely terminated.  As  a  palliative  measure,  small  punc- 
tures may  be  made  with  a  narrow-bladed  scalpel. 

Erysipelas  of  the  Vulva. — This  generally  follows 
labor,  and  occasionally  wounds  of  the  vulva.  It  behaves 
in  the  same  way  as  when  affecting  the  skin  elsewhere ;  but 
owing  to  the  laxity  of  the  connective  tissue  of  the  labia 
there  is  much  swelling.  Since  the  use  of  antiseptics  in 
midwifery  it  is  less  often  seen,  and  should  be  regarded  as  a 
preventable  disease,  at  any  rate  when  occurring  as  a  com- 
plication of  childbed. 

It  is  seldom  confined  to  the  vulva,  but  spreads  thence  to 
the  thighs,  abdomen,  and  buttocks.  The  labia  minora  are 
apt  to  suffer  severely,  for  their  blood-supply  is  interfered 
with,  and  ulceration,  perforation,  or  gangrene  may  follow. 
It  is  important  that  when  this  condition  exists  no  internal 


84  I^J^J-  ■  I  •"»  ^•-  ••>    0/'\  WOMEN. 

examination  should  be  made;  otherwise  the  internal  organs 
may  be  infected  and  septicaemia  supervene. 

The  treatment  is  that  of  erysipelas  in  any  other  part  of 
the  body. 

Gangrene  of  the  Vulva. — This  occurs  under  the  fol- 
lowing conditions  : 

1.  As  the  result  of  injury,  especially  long-continued 
pressure  of  the  head  in  the  third  stage  of  labor,  or  from 
the  unskilful  use  of  instruments. 

2.  Following  cedema,  cellulitis,  or  erysipelas  of  the  vulva. 

3.  As  a  complication  of  some  of  the  exanthemata,  as 
small-pox,  scarlet  fever,  measles,  and  typhus. 

4.  In  underfed  and  dirty  children,  when  it  is  analogous  to 
noma  or  cancrum  oris. 

5.  As  a  result  of  phagedenic  ulceration. 

Except  in  the  last  case,  when  the  clitoris  is  apt  to  be  in- 
volved, the  nympha:  are  most  apt  to  suffer ;  they  ma)-  be 
perforated,  or  the  lower  portion   may  slough  off 

The  treatment  consists  in  supporting  the  patient's  strength  ; 
in  keeping  the  parts  as  clean  as  possible  with  antiseptic 
applications  ;  and  in  relieving  pain  by  hot  fomentations,  with 
opium  internally,  if  necessary. 

Abscess  of  the  Vtllva. — This  is  occasionally  due  to 
injury  or  to  suppuration  following  on  cellulitis,  er}^sipelas, 
or  hajmatoma.  But  in  many  cases  it  arises  in  the  sebaceous 
glands  of  the  labia  and  in  the  ducts  of  Bartholin's  glands. 
As  a  rule,  one  side  only  is  affected.  As  might  be  expected, 
gonorrhoea  is  the  principal  cause. 

The  signs  arc  those  of  an  abscess  in  other  situations, 
local  redness,  swelling,  heat,  and  pain,  often  accompanied 
with  febrile  symptoms. 

Treatment. — This  consists  in  a  free  incision  to  evacuate 
the  pus,  warm  bathing  followed  b}'  fomentations,  and  strict 
cleanliness. 


CHAPTER   VIII. 

DISEASES  OF  THE  VULVA  (Continued). 

CUTANEOUS  AFFECTIONS,    PRURITUS,  AND 
KRAUROSIS. 

"E^czetna  of  the  Vulva. — The  mucous  surface  is  not,  as  a 
rule,  involved,  but  the  cutaneous  surface  presents  a  number 
of  papules  which  become  vesicular  and  break,  allowing  of 
the  escape  of  serous  fluid ;  the  vesicles  then  dry  up  with 
the  formation  of  small  scales.  The  intervening  skin  is  hot 
and  erythematous.  Successive  crops  of  vesicles  may  ap- 
pear. Eczema  is  found  associated  with  some  constitutional 
conditions,  as  diabetes,  rheumatism,  and  gout ;  and  some- 
times with  local  conditions  in  which  irritating  discharges  are 
present — e.  g.  vesico-vaginal  fistula  and  endometritis.  It 
rhay  run  an  acute  or  a  chronic  course.  The  most  trouble- 
some symptom  is  irritation,  which  causes  scratching  and 
thereby  aggravation  of  the  disease.  Menstrual  disorders 
are  frequent  (Hebra). 

Treatment. — The  vulva  should  be  kept  clean  and  dry. 
Frequent  bathing  with  boracic  lotion  and  dusting  with 
oxide-of-zinc  powder  will  suffice  in  mild  cases.  When  ob- 
stinate, and  when  the  skin  has  become  white,  thickened, 
and  cracked,  the  vulva  should  be  painted  over,  under  an 
anaesthetic,  with  carbolic  acid,  one  part  to  four  of  glycerin, 
and  a  simple  dressing,  such  as  a  boracic  ointment,  applied. 

Constitutional  causes  must  at  the  same  time  receive  ap- 
propriate attention. 

Herpes  of  the  Vulva. — This  is  also  a  vesicular  condition, 
but  the  vesicles  are  arranged  in  small  groups,  and  the  inter- 

85 


86  DISEASES  OF   WOMEN. 

veiling  erythema  is  less  marked,  or  absent.  The  vesicles 
may  run  together,  forming  bulla,*.  Herpes  is  not  infrequently 
associated  with  the  menstrual  periods,  especially  when  these 
are  characterized  by  dysmenorrhea ;  and  with  pregnancy. 
If  a  herpetic  patch  ulcerates,  it  may  resemble  a  chancre, 
especially  if  the  inguinal  glands  are  affected.  Great  irrita- 
tion is  the  principal  symptom. 

Treatment. — This  is  similar  to  that  recommended  for 
eczema. 

I/UpUS  of  the  Vulva. — Probably  many  distinct  condi- 
tions have  been  described  under  this  name,  such  as  various 
syphilides  when  ulceration  has  occurred,  gummata,  and 
elephantiasis.  The  condition  found  in  kraurosis,  when 
there  are  small  reddened  sensitive  patches,  has  been  called 
lupus,  and  indeed  the  latter  term  has  been  loosely  applied 
to  almost  any  ulceration  of  the  pudenda. 

It  is  better  to  restrict  the  term  "  lupus  "  to  tubefculous 
skin  lesions ;  and  in  this  sense  lupus  of  the  vulva  is  ex- 
ceedingly rare.  It  then  presents  the  characteristics  of 
lupus  as  seen  on  the  face,  and  may,  like  that,  be  mainly 
ulcerative  or  mainly  hypertrophic  and  "tubercular"  in 
form.     It  runs  a  chronic  course. 

Syphilis. — This  disease  may  manifest  itself  on  the  vulva 
as  a  primary  sore  (chancre),  or  as  mucous  plaques  and  tu- 
bercles. Tertiary  lesions  and  gummata  are  uncommon. 
In  the  late  stages  the  opposed  surfaces  of  the  labia  are 
liable  to  a  change  similar  to  that  often  seen  on  the  tongue, 
and  known  as  leucoplakia.  Vulvar,  like  lingual  leucoplakia, 
may  ulcerate  and  become  a  precursor  of  epithelioma.  In 
infancy  congenital  .syphilis  sometimes  declares  itself  in  the 
labia  in  characteristic  coppery-red  spots. 

Elephantiasis. — This  affection  is  common  in  tropical 
countries,  but  is  rare  in  Europe.  It  consists  of  hypertrophy 
of  the  subcutaneous  connective  tissues,  accompanied  by 
dilatation  and  thrombosis  of  lymphatic  vessels  and  spaces. 
This  chansfe  is   often  associated  with  filaria  in  the  blood. 


DISEASES   OF   THE    VULVA.  ^7 

The  skin  is  generally  thickened  and  rugose,  like  the  rind  of 
an  orange,  and  pale.  The  labia  majora  are  its  favorite  seats  ; 
more  rarely  it  affects  the  clitoris,  and  still  more  rarely  the 
labia  minora.  The  legs  may  be  affected  at  the  same  time. 
When  the  enlargement  is  great  and  much  discomfort  is 
caused  by  the  heavy  pendulous  masses  (which  sometimes 
weigh  many  pounds),  they  should  be  removed  with  the 
scalpel  or  thermo-cautery. 

Pruritus. — Itching  of  the  vulva  may  arise  from  a  vari- 
ety of  causes.  They  may  be  arranged  in  three  groups  : 
I.  Irritating  Discharges;  II.  Diseases  of  the  Vulva;  and 
III.   Reflex  Irritation. 

Group  I. — This  will  include  diabetes,  cystitis,  and  leu- 
corrhoea. 

(a)  Diabetes. — The  margins  of  the  urethra  and  the  vesti- 
bule are  congested.  The  examination  of  the  urine  and  the 
history  of  the  case  will  establish  the  diagnosis.  The  irrita- 
tion may  be  lessened  by  sedative  applications  to  the  vulva 
and  urethra.  Pruritus  is  often  the  first  symptom  which 
leads  to  the  detection  of  diabetes. 

(b)  Cystitis. — The  pruritus  is  generally  a  minor  feature, 
and  is  usually  relieved  by  washing  out  the  bladder. 

(c)  Lcucorrluva. — In  view  of  the  number  of  instances  in 
which  leucorrhcea  exists  without  pruritus,  it  seems  doubt- 
ful whether  this  cause  can  act  alone,  without  some  predis- 
posing or  accessory  condition.  Nevertheless,  the  cure  of 
the  vaginitis  or  endometritis,  as  the  case  may  be,  will 
generally  be  followed  by  disappearance  of  the  pruritus. 
In  many  cases  the  inflammation  has  started  with  gonor- 
rhoea; and  then  the  concurrent  urethritis  helps  to  keep 
up  the  irritation. 

Group  II. — (a)  Congestion  of  tlic  Vnlva. — This  may  be 
due  to  varicose  veins  caused  by  pressure  in  the  pelvis  ;  or 
to  functional  causes.  In  the  former  case  the  causal  condi- 
tion must  be  dealt  with  ;  the  possible  conditions  are  retro- 
version of  the  gravid  uterus,  simple  pregnancy,  a  uterine  or 


88  DISEASES   OE   WOMEN. 

ovarian  tumor  blockint:^   up  the  pelvis,  pelvic   cellulitis,  or 
intra-abdominal  pressure  on  the  vena  cava. 

Functional  congestion  may  be  associated  with  the  men- 
strual epochs,  and  the  jjruritus  will  then  be  periodic  ;  or  it 
may  be  due  to  masturbation.  The  latter  is  not  infrequently 
associated  with  pruritus,  but  whether  as  cause  or  effect  it 
would  be  difficult  to  decide. 

(b)  llihitis. — The  skin  of  the  affected  parts  is  at  first  red 
and  hot ;  later  it  becomes  pale,  thickened,  and  cracked,  ap- 
pearing as  if  sodden  ;  often  there  are  marks  due  to  scratch- 
ing. It  is  always  worse  at  night.  Treatment  may  be  begun 
in  mild  cases  by  sedative  and  cooling  applications,  such  as 
evaporating  lotions,  glycerole  of  belladonna,  or  opium  or 
cocaine  ointment.  In  more  obstinate  cases  the  parts  should 
be  painted,  under  ether,  with  a  solution  of  carbolic  acid  in 
glycerin  (i  :  5),  and  the  resulting  sore  treated  with  non-irri- 
tating dressings.  Other  caustics  also  have  been  recom- 
mended ;  but  this  is  one  of  the  most  successful.  Cure 
will  follow  in  most  cases,  though  several  applications  may 
be  required.  If  this  fails  there  is  only  one  course  left — 
viz.  to  excise  the  affected  parts. 

(c)  Pcdiailns  Pubis. — This  is  readily  recognized  on  in- 
spection. The  pubes  -should  be  shaved  and  thoroughly 
cleansed  with  a  solution  of  perchloride  of  mercury  (1:1000). 

Group  III. — Reflex  Causes. — (a)  From  the  Reetum. — 
Thread-worms  may  be  responsible,  or  some  unhealthy  con- 
dition of  the  rectal  mucous  membrane,  such  as  anal  fissure, 
or  a  rectal  polypus.  Pruritus  ani  is  generally  added  to  pru- 
ritus vulvre  in  these  cases. 

(b)  From  the  Bladder. — In  cases  of  vesical  irritability 
with  frequent  micturition  pruritus  may  be  present  as  a  re- 
flected neurosis.  Bladder  sedatives,  such  as  hyoscyamus 
and  belladonna,  are  then  indicated. 

(c)  From  the  Uterus. — Pregnancy  sometimes  is  associated 
with  pruritus,  even  when  there  is  not  marked  leucorrhea. 

Kraurosis  Vulvae. — This  disease  to  which  Breisk}-  in 


DISEASES   OE   THE    VULVA.  89 

1885  gave  the  name  kraurosis  (xpaopo^,  dry,  withered)  was 
first  accurately  described  by  Lawson  Tait,  in  1875,  as  an 
atrophic  change  affecting  the  nyniph;u. 

Symptoms. — The  patient  complains  of  irritation  referred 
to  the  vulva,  excessive  pain  during  sexual  intercourse  and 
on  passing  water,  and  of  a  yellowish  discharge.  The  irri- 
tation is  worse  when  the  patient  is  warm  in  bed,  and  com- 
monly disturbs  or  prevents  sleep.  As  a  result,  the  general 
health  is  impaired,  the  appetite  fails,  and  the  face  has  a 
harassed  look. 

Physical  Sig)is. — In  the  early  stage  the  skin  of  the  labia 
minora,  vestibule,  and  clitoris  is  smooth  and  shiny ;  the 
urethral  meatus  presents  a  red,  caruncular  appearance,  and 
along  the  margins  of  the  carunculae  myrtiformes  there  are 
small  patches  as  of  subcutaneous  haemorrhage,  which  are 
often  exceedingly  tender  to  the  touch.  Later,  the  nymphae 
diminish  and  finally  disappear,  while  the  orifice  of  the  vagina 
becomes  so  contracted  that,  even  in  a  multipara,  it  will 
barely  admit  a  finger.  The  pubic  hair  has  a  peculiar  stub- 
bly aspect,  and  near  the  labia  majora  may  be  coarse  and 
broken.  In  the  final  stages  the  vulva  is  very  pale,  with  a 
look  as  if  it  had  been  ironed,  all  folds  and  creases  having 
been  smoothed  out. 

The  vagina,  above  the  hymen,  is  not  affected  ;  the  labia 
majora  also  generally  escape,  but  in  many  patients  kraurosis 
of  the  vulva  is  associated  with  marked  atrophy  of  the 
uterus. 

Pathology. — The  disease  occurs  mostly  after  the  age  of 
forty  ;  its  cause  is  unknown.  It  is  best  described  as  a  pro- 
gressive atrophy  of  the  vestibule  and  nymphae. 

Microscopically  the  affected  parts  show  great  increase  of 
fibrous  tissue,  running  principally  in  bands  parallel  to  the 
surface.  The  vessels  and  nerves  are  compressed  as  they 
pass  between  these  bands,  and  this  accounts  for  the 
petechial  hemorrhages  and  the  great  sensitiveness  found  in 
the  early  stages,  and  for  the  bloodlessness  and  comparative 


90  DISEASES   OF   WOMEN. 

inscnsil)ility  later  on.  Tlic  papilhc  arc  small,  the  rete  Mal- 
pit^iiii  thin,  ant!  the  sebaceous  and  sweat  glands  disappear. 

Course  and  Prognosis. — The  disease,  if  left  alone,  runs  a 
chronic  course  of  five  or  six  years ;  durinj^  this  time  there 
is  great  suffering  and  discomfort,  but  ultimately,  when  the 
atrophy  is  complete,  the  pain  disappears.  The  parts  remain 
friable  ;  even  coitus  may  cause  troublesome  lacerations,  and 
these  are  considerable  if  pregnancy  and  labor  supervene. 

TrcatDioit. — Palliative  measures  are  unsatisfactory.  Sed- 
ative lotions,  cocaine  ointment,  etc.  give  only  temporary 
relief  The  pruritus  may  be  stopped  for  a  time  by  painting 
over  the  affected  parts,  under  ana,'sthesia,  with  a  20  per 
cent,  solution  of  carbolic  acid  in  glycerin.  Failing  such 
remedies  the  application  of  the  thermo-cautery  to  the  red 
and  painful  spots  is  very  useful.  Occasionally  it  is  neces- 
sary to  excise  the  affected  parts. 


CHAPTER   IX. 


DISEASES   OF   THE   VULVA    (Continued). 


MORBID  CONDITIONS  OF  HYMEN,  CLITORIS, 
URETHRAL  ORIFICE,  AND  PERINEUM. 

The  Hymen. — Normally,  the  hymen,  when  stretched, 
forms  a  diaphragm  with  a  central  perforation  situated 
nearer   the  anterior    than  the  posterior    margin   (Fig.    28). 


D  E  F 

Fig.  28. — Variations  in  the  shape  of  the  liytneneal  aperture  :  A,  normal  ;  B,  crcs- 
ccntic  ;  C,  fringed  :  /',  tlivideU  by  transverse  band;  if,  divided  by  antero-posterior  band; 
F,  cribriform  (A.  E.  G.)- 

91 


92  DISEASES   OE   II  OMEN. 

The  variations  are  as  follows :  A  small  circular  aperture, 
centrally  situated  (./) ;  a  crescentic  fold  posteriorly,  the 
aperture  bein<^  anterior  (Zf) ;  a  fringed  condition  in  which 
the  margin  is  indented  in  several  places  (c) ;  a  double  ori- 
fice with  a  transverse  division  {d)  ;  a  double  orifice  with  an 
antero-posterior  division  (Zf) — this  resembles  the  external 
appearance  of  a  double  vagina,  for  which  it  must  not  be 
mistaken  ;  lastly,  the  cribriform  h>'men  (/),  in  which  there 
are  several  perforations. 

Variations  in  Structure. — It  may  be  very  thin  and  easily 
torn ;  or  dense  and  unyielding,  requiring  division  before 
coitus  can  take  place ;  or,  thick  and  fleshy.  It  may  be 
unusually  distensible  and  yielding,  so  that  a  finger  or  small 
speculum  may  be  introduced,  or  coitus  occur,  without  rup- 
ture. When  the  legs  are  separated  the  hymen  may  be- 
come so  tense  that  the  finger  cannot  be  introduced,  whilst  it 
may  pass  easily  when  the  thighs  are  approximated  (Brouardel). 

This  small  structure  has  therefore  an  important  medico- 
legal bearing.  A  permeable  hymen,  or  one  of  the  shape 
shown  in  Fig.  28,  D,  must  not  be  taken  as  a  certain  indi- 
cation that  intercourse  has  taken  place ;  and  secondly,  an 
unruptured  hymen  is  not  positive  proof  of  virginity. 

Treatment. — A  rigid  or  contracted  hymen  may  require 
dilatation  or  division,  to  allow  of  coitus  taking  place. 

Carunculse  hymenales  result  from  the  rupture  of  the 
hymen  caused  by  coitus  ;  they  consist  of  the  portions  of  the 
hymen  which  are  left  between  the  radiating  tears,  and  touch 
one  another  so  that  in  the  undisturbed  condition  the  hymen 
may  still  appear  intact.  When  everted  they  resemble  the 
petals  of  a  daffodil. 

Carunculse  myrtiformes  are  due  to  more  extensive 
stretching  of  the  hymen,  as  during  childbirth.  They  ap- 
pear as  isolated  nodules  round  the  hymeneal  margin,  and 
are  produced  by  tearing  through  of  the  base  of  the  hymen. 

Cysts. — Small  cysts  lined  with  ejiithelium  sometimes 
form  in  the  tissues  of  the  hymen. 


DISEASES   OE   THE    VULVA.  93 

Painful  caruncles  of  the  hymen  arc  a  frequent  source 
of  vaginismus  and  dyspareunia.  They  appear  as  a  series  of 
congested  spots,  resembling  small  recent  bruises,  and  ex- 
ceedingly sensitive,  situated  at  the  hymeneal  margin.  They 
occur  principally  in  cases  of  kraurosis  vulvae,  and  are  often 
found  associated  with  urethral  caruncle.  For  treatment 
see  Kraurosis. 

Imperforate  hymen  is  considered  under  the  head  of 
Atresia  Vulvae  (p.  6'6\ 

The  rupture  of  the  hymen  is  generally  attended  by 
pain  of  short  duration  and  slight  bleeding.  The  latter 
may  occasionally  be  so  profuse  as  to  demand  surgical 
intervention,  and  may  even  be  fatal. 


MORBID  CONDITIONS  OF  THE  CLITORIS. 

Inflammation. — This  may  form  part  of  a  general  vul- 
vitis, or  it  may  be  due  to  the  development  of  a  venereal  sore 
or  phagedenic  ulcer.  In  other  cases  the  prepuce  becomes 
adherent  to  the  glans  of  the  clitoris,  and  the  pent-up  secre- 
tion (smegma)  sets  up  irritation  which  may  lead  to  ulcera- 
tion or  a  small  abscess.  The  treatment  of  this  condition 
consists  in  separating  the  adherent  margins  of  the  prepuce 
and  keeping  the  parts  clean  and  dry. 

Elephantiasis  is  usually  associated  with  elephantiasis 
vulvae ;  occasionally  the  clitoris  is  affected  independently  of 
the  labia  and  forms  a  tumor  hanging  down  as  a  large  mass 
in  front  of  the  vulva. 

epithelioma. — This  is  a  somewhat  rare  affection  of  the 
clitoris.  The  prognosis  after  removal  is  favorable,  as  the 
glands  are  affected  very  late  and  there  is  but  little  tendency 
to  deep  or  extensive  spreading. 

Treatment. — This  consists  in  complete  extirpation  of  the 
clitoris  and  its  crura. 

Urethral  Caruncle. — This  is  a  small  red  fleshy  growth 
situated  on  the  posterior  aspect  of  the  urethral  meatus. 


94  DISEASES   OE   WOMEN. 

Pathology. — It  occurs  at  or  after  middle  life.  It  is  often 
associated  with  kraurosis  vulva;,  and  in  these  cases  it  is 
probably  due  to  the  atrophic  changes  which  characterize 
that  condition  ;  for  there  is  often  a  strikinf,^  similarity  be- 
tween some  kinds  of  urethral  caruncle  and  those  red  and 
tender  spots  round  the  hymeneal  margin  which  occur  so 
constantly  in  kraurosis. 

In  other  cases,  however,  there  is  no  accompanying  krau- 
rosis, and  the  caruncle  is  then  usually  larger  and  more 
prominent,  and  is  due  in  all  probability  to  changes  taking 
place  in  Skene's  ducts,  two  small  recesses  in  the  floor  of 
the  urethra.  It  is  possible  that  these  changes  have  an  in- 
fective origin,  but  their  pathology  is  not  quite  clear.  In 
some  cases  the  structure  of  the  caruncle  is  suggestive  of 
adenoma ;  in  others  the  principal  feature  consists  in  the 
increase  of  thin-wallcd  vessels  like  those  seen  in  piles,  and 
has  suggested  the  name  urethral  hemorrhoid.  The  view 
that  a  caruncle  is  always  due  to  changes  occurring  in  the 
urethral  ducts  receives  strong  support  from  the  fact  that 
the  caruncle  is  invariably  situated  on  the  floor  of  the  urethra 
in  the  situation  of  the  ducts. 

Symptoms  and  Signs. — The  patient  complains  as  a  rule 
of  pain  and  tenderness" at  the  meatus,  with  a  burning  sensa- 
tion on  passing  water,  and  sometimes  of  frequency  of 
micturition.  Occasionally  the  caruncle  gives  rise  to  bleed- 
ing and  pain  on  coitus.  A  caruncle  is  readily  recognized 
on  inspection,  presenting  the  characters  above  described. 
It  often  extends  from  one  to  two  centimetres  up  the  urethra. 

Treatment. — The  simplest  plan  is  to  remo\'e  the  small 
growth  with  scissors,  or  to  destroy  it  with  the  thermo-cau- 
tery  under  an  anaesthetic. 

THE  PERINEUM. 

This  term  is  applied  to  the  cutaneous  and  subcutaneous 
tissues  intervening  between  the  fourchette  and  the  anterior 
margin   of  the   anus.     Its  centre  corresponds  to  what  is 


DISEASES   OF  THE    VULVA.  95 

known  in  the  male  as  the  central  point  of  the  perineum. 
On  section  (Fig.  i)  it  is  triangular  and  marks  the  meeting 
of  the  sphincter  of  the  anus,  the  transverse  perineal  and  the 
rudimentary  bulbo-cavernosus  muscles.  It  also  contains  a 
strong  meshwork  of  connective  tissue,  and  fibres  of  elastic 
tissue  intermingle  with  the  confluent  attachments  of  the 
muscles   mentioned  above. 

Ruptured  Perineum. — By  this  is  meant  a  tear  extend- 
ing through  the  lower  part  of  the  posterior  vaginal  wall 
and  the  perineum  ;  it  may  extend  into  the  anus. 

Causes. — It  is  almost  invariably  due  to  parturition,  but 
occasionally  it  is  produced  by  surgical  procedures,  such  as 
the  extraction  of  large  uterine  polypi  or  foreign  bodies  from 
the  vagina. 

When  it  occurs  during  labor  the  predisposing  circum- 
stances are — 

1.  Disproportion  between  the  size  of  the  head  and  the 
genital  passages. 

2.  Precipitate  labor. 

3.  Want  of  care  in  the  delivery  of  the  head  or  shoulders. 

4.  Certain  malpresentations,  especially  the  unreduced 
occipito-posterior. 

5.  The  use  of  instruments.  The  application  of  forceps 
does  not,  however,  necessarily  endanger  the  perineum  ;  on 
the  contrary,  properly  used,  it  may  lessen  the  risk  of  injury, 
by  controlling  and  guiding  the  expulsion  of  the  head. 

6.  Morbid  conditions  of  the  perineum  :  as  undue  softness 
and  friability,  which  may  be  due  to  long-continued  pressure 
of  the  child's  head;  undue  rigidity;  or  diminution  of  elastic- 
ity as  the  result  of  chronic  inflammation. 

7.  The  risk  is  greater  in  primipara;,  and  increases  with 
the  age  of  the  primipara. 

Varieties. — The  following  are  met  with  : 

I.  Partial. — Little  more  than  the  fourchette  may  be  in- 
volved ;  or  the  perineum  may  be  divided  to  a  greater  or 
less  extent,  but  the  sphincter  ani  remains  intact.     W^ithiii 


g6  DISEASES   OE   WOMEN. 

tlic  vagina,  the  tear  nearly  always  occurs  to  one  or  other 
side  of  the  posterior  va^nnal  column.  The  tliickness  and 
firmness  of  this  structure  prevent  a  median  split. 

2.  Complete. — The  laceration  is  anteriorly  the  same  as  in 
the  partial  variety,  but  posteriorly  it  extends  throuj^^h  the 
sphincter  ani,  and  may  pass  for  some  distance  up  the  anterior 
wall  of  the  rectum. 

3.  Central. — In  this  kind,  which  is  uncommon,  the  ante- 
rior pari  of  the  perineum  remains  intact,  but  a  tear  occurs 
at  some  place  between  the  faurchette  and  the  anus.  It  is 
due,  as  a  rule,  to  long-continued  pressure  of  the  child's 
head,  whereby  the  vitality  of  the  thinned-out  perineum  is 
so  impaired  that  it  gives  way  at  its  most  prominent  point. 
Or  perforation  may  occur  later  from  gangrene,  a  vagino- 
perineal fistula  thus  resulting.  Cases  have  also  been  re- 
corded in  which  the  central  tear  was  so  large  that  the  child 
was  born  through  it,  passing  out  behind  the  posterior  com- 
missure of  the  vagina. 

Res7ilts  of  Ruptured  Perine?aii. — When  the  rupture  is 
partial,  there  is  a  tendency  to  prolapse  of  the  vaginal  walls, 
especially  the  posterior;  this  may  be  followed  by  a  more 
complete  hernia  of  the  pelvic  floor.  There  is  also  inability 
to  retain  a  pessary  when  this  is  indicated  on  account  of 
prolapse  or  retroversion. 

When  the  rupture  is  complete,  in  addition  to  the  conse- 
quences mentioned  above,  there  is  diminution  or  loss  of 
control  over  the  rectum,  causing  incontinence  of  faeces  or 
flatus. 

Treatment. — When  a  perineum  becomes  torn  during  par- 
turition, it  should  always  be  repaired  at  once.  Two  or 
three  sutures  will  usually  suffice,  and  union  readily  occurs. 
When  not  seen  till  some  time  after,  secondary  perineor- 
rhaphy is  required. 


CHAPTER   X. 

DISEASES  OF  THE  VULVA  (Continued). 

TUMORS   AND   CYSTS. 

The  vulva  is  liable  to  lipomata,  myxomata,  sarcomata, 
angciomata,  papillomata,  epithelioma,  and  carcinoma. 

I/ipomata. — These  may  arise  in  the  fatty  tissue  of  the 
mons  or  in  the  deep  connective  tissue  of  the  labia ;  they 
usually  form  sessile  tumors,  but  may  be  pedunculated.  A 
sessile  lipoma  is  apt  to  be  mistaken  for  an  omental  hernia 
occupying  the  canal  of  Nuck,  and  vice  versa. 

Myxomata. — These  form  irregular  lobulated  peduncu- 
lated tumors  of  the  labium  ;  they  are  usually  single  and  the 
skin  covering  them  is  deeply  pigmented. 

Sarcomata. — These  are  very  rare ;  the  commonest  spe- 
cies is  melanoma  (melanotic  sarcoma),  arising  in  the  pig- 
mented tissues  of  the  greater  labium.  They  are  usually 
rapidly  fatal  from  dissemination. 

Angeiomata. — Nsevi  occur  in  the  labia  of  children ;  the 
more  serious  plexiform  angeioma  is  very  rare. 

Papillomata  (JVarts). — These  are  very  common  on  the 
vulva  and  surrounding  cutaneous  surface,  and  are  often  asso- 
ciated with  irritating  vaginal  discharges,  especially  gonor- 
rhoeal. 

Kpithelioma. — This  arises  on  any  part  of  the  vulva 
and  occasionally  occurs  primarily  on  the  clitoris.  It  is  rare 
before  middle  life,  but  the  liability  increases  with  advancing 
years.  The  opposed  surfaces  of  the  labia  are  liable  to 
those  changes  so  often  seen  on  the  tongue  and  known  as 
leucoplakia ;  vulvar-likc  lingual  Icucoplakia  may  be  the 
7  'J7 


98  DISEASES   OE   WOMEN. 

precursor  of  epithelioma.  Epithelioma  of  the  vulva  runs 
much  the  same  course  as  in  other  situations  and  quickly 
involves  the  inguinal  lymph-glands.  In  the  late  stages  foul 
ulcerating  cavities  form,  and  the  depressions  formed  by  the 
primary  disease  and  those  resulting  from  the  necrosis  of 
the  infiltrated  glands  join  to  form  a  continuous  bleeding 
and  discharging  cavity.  Death  comes  about  from  exhaus- 
tion and  distress  induced  by  pain,  frequent  bleedings,  and 
mental  anguish.  Sometimes  a  large  vessel  is  opened  by 
ulceration,  and  rapid  death  from  bleeding  ensues. 

Diagnosis. — This  is  usually  easy ;  the  conditions  most 
likely  to  be  mistaken  for  it  are — 

{a)  Papillomata,  especially  if  inflamed  or  ulcerating. 

{6)  Hard  chancre.  This  forms  a  single  ulcer,  with  hard 
base,  and  no  tendency  to  spread.  The  inguinal  glands  are 
small,  separate,  and  amygdaloid. 

{c)  Soft  chancres  are  multiple ;  there  is  no  induration  ; 
and  they  heal  rapidly  under  proper  treatment. 

{li)  Lupus  is  distinguished  by  alternations  of  tubercular 
masses,  ulcers  with  bluish  undermined  edges,  and  contract- 
ing cicatrices.  There  may  also  be  tracts  of  healthy  skin 
between  the  ulcers,  whilst  the  cancerous  ulcer  is  compact 
and  shows  no  tendency  to  heal. 

{/)  Sloughing  phagedena  appears  as  a  breaking-down 
abscess  with  gangrenous  walls  and  free  secretion  of  pus. 
There  is  no  induration,  and  the  history  of  venereal  infection 
points  to  its  true  character. 

Treatment. — If  seen  early  enough,  free  excision  is  the 
proper  treatment  and  the  prognosis  is  generally  good. 
When  practicable,  the  cut  edges  of  the  vagina  should 
be  sutured  to  the  skin  at  the  margin  of  the  wound  ;  the 
urethral  mucous  membrane  should  be  similarly  treated 
when  the  growth  surrounds  the  urethral  meatus.  When 
the  clitoris  is  alone  affected,  complete  extirpation  of  this 
appendage  is  necessary. 

If  the  growth  has  extended   deeply  into  the  vagina,  or 


DISEASES    OF    THE    VULVA.  99 

has  spread  extensively,  palliative  treatment  is  alone  possible. 
The  discomfort  may  be  relieved  by  frequent  antiseptic  irri- 
gations and  dressings  smeared  with  eucalyptus  and  vase- 
line; anodynes,  of  which  morphia  subcutaneously  admin- 
istered is  the  best,  are  usually  required  to  relieve  pain. 

Carcinoma. — This  is  a  very  rare  affection  of  the  vulva ; 
it  arises  in  Bartholin's  gl^id  and  involves  the  labial  tissues, 
infects  the  lymph-glands,  disseminates,  and  recurs  after  re- 
moval.    Structurally  it  mimics  the  acini  of  the  gland. 

Cysts  of  the  Vulva. — These  are  of  three  species : 
mucous,  sebaceous,  and  cysts  of  Bartholin's  glands. 

Mucous  Cysts. — These  are  found  principally  on  the 
inner  surface  of  the  labia  minora,  and  seldom  attain  a  large 
size.  They  should  be  opened,  and  if  they  recur  the  cyst- 
wall  should  be  dissected  out. 

Sebaceous  Cysts. — These  resemble  similar  cysts  in 
other  regions.  The  small  black  spot  marking  the  orifice 
of  the  duct  will  generally  give  the  clue  to  their  origin. 
They  are  liable  to  be  infected  by  vaginal  discharges  and 
then  usually  suppurate.  An  abscess  in  a  sebaceous  gland 
requires  free  incision  ;  an  enlarged  gland  requires  excision. 

Cysts  of  Bartholin's  Gland. — These  usually  arise  in 
the  duct,  but  in  chronic  cases  the  gland  may  enlarge. 
Sometimes  the  occlusion  is  not  complete ;  the  duct  may 
then  become  dilated  for  a  day  or  two,  and  this  is  followed 
by  a  sudden  discharge  of  mucous  fluid.  In  the  case  of 
complete  retention  the  fluid  may  be  watery  or  viscid  ;  oc- 
casionally it  resembles  the  contents  of  a  ranula. 

Symptoms  and  Cmwsc. — The  patient  complains  chiefly  of 
discomfort,  sometimes  of  pain.  The  inconvenience  may  be 
felt  in  walking  or  sitting,  whilst  the  pain  may  be  a  constant 
aching  due  to  distention,  or  take  the  form  of  dyspareunia. 

An  inflammatory  condition  may  be  present  from  the  first 
as  a  complication  of  gonorrhoea.  Pus  is  then  found  e.xuding 
in  small  drops  from  the  duct-orifice;  later  this  tends  to 
close  up,  and  abscess  results. 


lOO 


DISEASES   OE   WOMEN. 


A  simple  cyst  is  fairly  well  diftcrcutiated  from  the  sur- 
rounding structures  ;  but  if  suppuration  sets  in,  the  cyst- 
walls  become  thickened  and  infiltrated,  and  the  distinc- 
tion between  them  and  surrounding  tissues  is  obscure. 
When  an  intermitting  cyst  is  examined  during  its  stages  of 
collapse,  the   gland  itself  may  be  felt,  between  the  finger  in 


Vestibular  bulb. 


Bartholin' s  gland. 
The  duct. 


Fig.  29.— The  right  labium  majus  dissected  to  show  Bartholin's  gland  and  its  duct  (semi- 
diagrammatic). 


the  vagina  and  the  thumb  outside,  as  a  little  mass  the  size 
of  a  pea  or  small  bean. 

Diagnosis. — The  cyst  presents  a  characteristic  pear-shaped 
swelling,  occupying  the  most  dependent  part  of  the  labium 
majus,  the  narrow  end   of  the  swelling   being  uppermost. 


DISEASES   OE   THE    VULVA.  lOI 

It  is  only  when  it  gets  large  that  it  involves  the  upper  part 
of  the  labium.  In  chronic  cases  the  orifice  is  readily  seen 
as  a  small  pit  in  the  angle  between  the  hymen  and  the  la- 
bium minus  (Fig.  29).  The  lesser  lip  is  not  affected  when 
the  cyst  is  small ;  when  large,  it  is  stretched  and  flattened 
over  the  swelling.  Suppuration  is  readily  recognized  by 
the  much  greater  pain,  the  redness  of  the  skin  and  mucous 
membrane,  and  the  heat  of  the  part. 

Three  conditions  require  to  be  differentiated  from  a 
Bartholinian  cyst  or  abscess : 

(a)  Hcematoma. — The  swelling  is  more  uniform  through 
the  labium  majus  ;  it  feels  usually  more  doughy,  and  there 
is  commonly  a  history  of  injury  or  recent  parturition.  A 
haimatoma  may  affect  the  lesser  lip  alone. 

(b)  Ingidnal  Hernia. — This  appears  at  the  upper  end  of 
the  greater  lip,  and  tends  to  disappear  when  the  patient  is 
lying  down ;  there  is  an  impulse  on  coughing,  and  it  may 
be  resonant.  In  any  case  there  is  not  a  free  flattened  space 
between  the  swelling  and  the  inguinal  opening. 

(c)  Hydrocele  of  the  Canal  of  Niick. — In  this  case  the 
swelling  occupies  the  upper  or  middle  part  of  the  labium, 
the  lower  end  being  free.  There  is  no  impulse  on  straining 
or  coughing,  nor  is  the  swelling  affected  by  the  position  of 
the  patient. 

Treatment. — The  only  satisfactory  way  of  dealing  with  a 
Bartholinian  cyst  is  to  dissect  it  out. 


CHAPTER  XI. 

DISEASES  OF  THE  VAGINA. 

AGE-CHANGES,  DISPLACEMENTS,  INJURIES, 
FOREIGN   BODIES,  AND   FISTUL/E. 

Age-changes  in  the  Vagina. — In  the  child  the 
vagina  forms  merely  a  transverse  slit.  The  walls  are 
thrown  into  numerous  close  folds,  mainly  transverse,  and 
more  marked  at  the  side. 

After  puberty  the  vai^ina  becomes  larger,  the  widening 
affecting  especially  the  upper  part.  There  are,  however, 
considerable  variations  in  individual  cases ;  in  some  the  va- 
gina remains  nearly  the  same  width  above  as  below  ;  in 
others,  the  capaciousness  superiorly  forms  a  marked  con- 
trast to  the  narrow  entrance. 

After  marriage  the  folds  become  somewhat  flattened  out, 
and  the  whole  vagina  becomes  dilated,  owing  to  the  ca- 
pacity of  its  walls  for  stretching. 

Childbirth  accentuates  the  changes,  and  after  repeated 
labors  the  folds  become  almost  obliterated,  and  the  orifice 
may  remain  gaping,  owing  to  stretching  or  rupture  of  the 
sphincter  vaginae.  At  the  same  time  the  walls  become  lax, 
and  tend  to  protrude  through  the  vulvar  orifice. 

With  the  onset  of  the  menopause,  atrophic  changes  set 
in.  The  walls  now  become  quite  smooth  on  the  surface ; 
and  the  lumen  becomes  contracted,  especially  at  its  upper 
portion  ;  with  the  result  that  the  fornices  are  obliterated, 
and  the  whole  vagina  assumes  a  conical  form,  with  its  apex 
upward.  At  the  summit  of  the  cone  the  cervix  forms  a 
small  projection  ;  or,  this  also  becoming  atrophied,  the  vag- 

1U2 


DISEASES   OF   T/IR    VAGINA.  IO3 

inal  vault  becomes  almost  pointed,  with  a  small  depression 
at  its  apex  representing  the  external  os  and  barely  admitting 
a  sound  or  a  probe. 

DISPLACEMENTS  OF  THE  VAGINA. 

These  are  commonly  associated  with  displacements  of 
the  uterus,  the  whole  forming  the  typical  "  hernia  of  the 
pelvic  floor ;"  but  as  the  vagina  may  be  affected  principally, 
or  alone,  we  shall  here  describe  the  two  chief  types — viz. 
cystocele  and  rectocele. 

Cystocele. — This  is  really  a  hernia  of  part  of  the  blad- 
der into  the  vagina,  the  vaginal  mucous  membrane  form- 
ing  its  outer  covering ;  or  it  may  be  expressed  as  a  deflec- 
tion of  the  vesico-vaginal  septum  toward  the  vagina.  It 
forms  a  smooth,  rounded  swelling,  which  bulges  through 
the  vulvar  aperture  when  the  patient  coughs  or  strains.  If 
the  lower  part  of  the  anterior  vaginal  wall  is  mainly  af- 
fected, the  swelling  is  more  properly  called  a  urctJirocclc  ;  in 
this  case  it  is  smaller,  and  the  thickened  urethra  can  be  felt 
as  a  median  projection  through  the  vaginal  wall. 

Rectocele. — This  is  a  hernia  of  the  rectum  into  the  va- 
gina, covered  by  the  mucous  membrane  of  the  posterior 
vaginal  wall.  It  forms  a  swelling  resembling  that  produced 
by  a  cystocele,  except  that  it  is  on  the  posterior  aspect  of 
the  vagina.  If  the  finger  be  introduced  into  the  rectum  it 
can  be  passed  into  the  pouch  in  the  vagina ;  and  similarly 
a  sound  introduced  into  the  bladder  can  be  passed  into  a 
cystocele. 

A  rectocele  is  nearly  always  associated  with  a  deficient 
perineurh  ;  and  further,  cystocele  and  rectocele  are  often 
found  together.  When  this  is  the  case  the  vulvar  outlet, 
when  the  patient  strains,  is  occupied  by  two  smooth  swell- 
ings placed  one  in  front  of  the  other ;  between  them  the 
finger  can  be  passed  up  to  the  cervix  (Fig.   30). 

Causes. — The  direct  cause  of  these  conditions  is  a  relaxa- 
tion of  the  tissues  forming  the  vaginal  walls.     This,  again, 


I04 


DISEASES   OF   WOMEN. 


is  brought  about  mainly  by  parturition.  Women  who  have 
iDorne  a  great  number  of  children  are  the  principal  sufferers, 
and  most  cases  come  under  observation  between  the  ages 


V-^' 


* 


Fig.  30. — Cystocelc  and  rectocele  (A.  E.  G.). 

of  thirty  and  forty-five.  After  the  menopause  the  general 
tendency  to  atrophy  of  the  genital  passages  counteracts  in 
some  measure  the  laxity  of  the  vaginal  walls. 

The  mechanism  of  the  displacement  differs  slightly  in  the 
production  of  a  cystocele  and  a  rectocele. 

Cystocelc. — It  will  be  remembered  that  the  anterior  vagi- 
nal wall  is  attached  more  firmly  below,  opposite  the  pubes, 
than  above ;  now  in  the  case  of  a  tedious  labor,  when  a 
large  head  presses  for  some  time  on  the  vaginal  walls,  the 
anterior  wall  is  forced  down,  and    its    attachments  to  the 


DISEASES   OF   THE    VAGINA.  I05 

pubes  are  loosened  and  may  even  be  separated.  After  a 
first  confinement  the  parts  may  regain  more  or  less  their 
normal  fixity.  But  after  repeated  labors,  especially  if  dif- 
ficult, the  lower  part  of  the  anterior  vaginal  wall  remains 
permanently  loosened  from  its  pubic  attachment,  and  tends 
to  prolapse  whenever  the  intra-pelvic  pressure  is  increased, 
as  when  the  bladder  is  full ;  when  the  patient  strains  at 
stool  or  coughs ;  and  in  some  cases  when  she  simply 
stands  erect. 

A  cystocele  may  arise  in  another  way.  Owing  to  the 
fact  that  the  principal  attachment  of  the  anterior  vaginal 
wall  is  at  its  lower  end,  it  follow's  that  if  the  uterine  sup- 
ports be  loosened,  and  the  uterus  comes  to  lie  low  in  the 
pelvis,  the  upper  and  lower  ends  of  the  anterior  vaginal 
walls  are  approximated ;  the  intervening  part  bulges  back- 
w^ard,  especially  when  the  bladder  is  full ;  and  in  this  way 
also  a  cystocele  is  produced. 

Rectocelc. — The  posterior  vaginal  wall  is  mainly  attached 
above,  being  held  in  place  by  the  utero-sacral  folds.  When 
these  are  lengthened  and  rendered  lax,  as  by  the  dragging 
of  a  heavy  uterus  or  as  the  result  of  repeated  labors,  the 
posterior  vaginal  wall  hangs  lower,  and  may  bulge  in  the 
form  of  a  rectocele.  The  tendency  to  this  is  greatly  in- 
creased if  the  perineum  be  torn,  as  the  inferior  support  is 
then  lost.  Indeed,  a  slight  degree  of  rectocele  is  possible 
when  the  perineum  is  torn,  even  if  the  utero-sacral  folds 
remain  at  a  normal  tension,  and  the  uterus  is  in  its  proper 
position.  But  it  is  evident  that,  owing  to  the  superior 
attachment  of  the  posterior  wall,  there  can  be  no  great  pro- 
lapse of  that  wall  as  long  as  those  attachments  remain  firm. 

In  accordance  with  the  above  considerations  we  find, 
first,  that  cystocele  is  more  common,  and  usually  more 
marked,  than  rectocele ;  secondly,  that  prolapse  of  the 
uterus  strongly  predisposes  to  prolapse  of  the  vaginal 
walls. 

Sy)iipto))is. — The  patient  complains  principally  of  "  bear- 


Io6  DISEASES   OE   WOMEN. 

iiig  down."  and  of  something  protruding  from  the  vulva. 
In  out-patient  practice  the  statement  made  is  often  that 
"  the  womb  comes  down."  The  feeling  of  weight  and 
dragging  is  aggravated  after  long  standing  or  walking,  and 
during  defecation.  With  cystocele  and  urethrocele  there  is 
often  frequency  of  desire  to  pass  water.  On  making  an 
examination,  the  vaginal  outlet  is  seen  to  be  occupied  by 
one  or  two  swellings  according  as  one  or  both  conditions 
exist.  In  recent  cases  the  mucous  membrane  retains  its 
normal  character;  in  those  of  long  standing  it  may  be 
thickened  and  hard,  approaching  the  appearance  of  the 
skin.  The  swelling  is  distinguished  from  a  protruding 
cervix  by  the  absence  of  the  os  externum  and  by  the  fact 
that  it  has  an  anterior  (cystocele)  or  a  posterior  (rectocele) 
attachment.  A  finger  passed  through  the  anus  into  the 
posterior  swelling,  or  a  sound  passed  through  the  urethra 
into  the  anterior  one,  will  confirm  the  diagnosis.  The  cerv'ix 
uteri  is  generally  met  with  low  down  in  the  vagina. 
Trcatuicnt  is  of  two  kinds,  palliative  and  curative. 

(a)  Palliative  treatment  consists  in  the  employment  of 
pessaries ;  of  these  the  most  useful  is  the  rubber  ring. 
When  the  perineum  is  much  torn,  it  is  often  found  that  no 
ring  will  remain  in  pcsltion,  unless  so  large  as  to  cause 
harmful  pressure.  An  instrument  of  the  cup-and-stem  t)-pe 
may  be  used,  such  as  a  ring  with  a  Y-shaped  stem,  the 
limbs  of  the  Y  being  attached  at  the  ends  of  a  diameter  of 
the  ring.  Perineal  bands  are  fastened  to  the  lower  end  of 
the  stem.  These  plans  are,  at  the  best,  faulty ;  and  when  a 
simple  ring  cannot  be  retained  it  is  much  better  to  resort  to 
operation  unless  contraindicated. 

(b)  Curative  or  Radical  Treatment. — Vox  rectocele,  a  peri- 
neorrhaphy may  be  performed,  either  alone  or  associated 
with  posterior  colporrhaphy  (colpo-perineorrhaplu')-  This 
will  often  allow  of  the  wearing  of  a  ring,  e\en  if  the  opera- 
tion does  not  entirely  cure  the  prolapse. 

For   cystocele    many   varietes   of  anterior   colporrhaphy 


DISEASES   OF   THE    VAGINA.  lO'J 

have  been  devised  (see  Colporrhaphy).  In  obstinate  cases 
some  more  serious  measure  may  be  tried,  such  as  vaginal 
or  ventro-fixation  (see  Hysteropexy).  For  cystocele  asso- 
ciated with  retroversion  of  the  uterus,  vagino-fixation  often 
answers  well ;  for  the  two  opposing  tendencies — of  the  ute- 
rus to  fall  back,  and  of  the  vaginal  wall  to  fall  down — coun- 
teract one  another  (Edge). 

Vaginal  Hernia  {Entcrocclc). — A  rare  form  of  hernia 
sometimes  occurs  in  which  the  uterus  and  the  lower  part 
of  the  vagina  retain  their  proper  position,  whilst  the  peri- 
toneal pouch  in  front  of  or  behind  the  uterus  bulges  into 
the  vagina  and  is  occupied  by  coils  of  intestine.  It  is  dis- 
tinguished from  the  conditions  just  described  by  the  follow- 
ing points  :  i.  The  swelling  is  not  continuous,  anteriorly  or 
posteriorly,  with  the  margin  of  the  vulva;  2.  The  finger  can- 
not be  passed  into  the  pouch  through  the  anus  nor  can  a 
sound  be  passed  into  it  through  the  urethra  ;  3.  The  cervix 
uteri  is  found  high  up. 

A  vaginal  hernia  has  been  mistaken  for  prolapse,  polypus, 
and  inversion  of  the  uterus. 

Injuries. — Serious  and  even  fatal  injuries  of  the  vagina 
have  followed  rape  on  adult  women  as  well  as  children ; 
severe  lacerations  have  been  caused  during  willing  coitus, 
due  to  unusual  size  of  the  penis,  undue  narrowness  of  the 
vagina,  or  even  awkwardness  on  the  part  of  the  man.  First 
coitus  sometimes  causes  alarming  and  even  perilous  bleed- 
ing, especially  when  the  laceration  of  the  hymen  extends  to 
and  involves  the  vulva  or  the  vaginal  wall. 

Fatal  peritonitis  has  followed  the  forcible  introduction  of 
foreign  bodies  by  brutal  men.  Women  sometimes  injure 
themselves  fatally  by  introducing  pointed  instruments  for 
the  purpose  of  inducing  abortion,  or  during  fits  of  sexual 
frenzy. 

The  upper  part  of  the  vagina  may  be  lacerated  by  the 
careless  use  of  instruments  in  operations  on  the  uterus  and 
during   instrumental  delivery,  or  by  the  child's  head  in  a 


I08  DISEASES   OE   WOMEN. 

long  second  stage  of  labor.  When  free  bleeding  results, 
it  may  be  erroneously  thought  to  be  derived  from  the 
cavity  of  the  uterus.  As  a  rule  the  bleeding  stops  readily 
under  the  influence  of  a  hot  vaginal  douche  (115°  F.).  If 
it  persists,  the  lacerations  may  require  to  be  repaired.  A 
serious  form  of  laceration  sometimes  occurs  during  labor, 
the  recto-vaginal  or  the  utcro-vesical  pouch  being  opened 
up.  This  may  occur  from  violent  uterine  contractions  in 
cases  where  the  pelvis  is  narrow  or  there  is  other  obstruc- 
tion to  delivery ;  it  has  also  been  produced  during  the 
introduction  of  the  forceps,  perforator,  or  cephalotribe. 
Coils  of  intestine  may  protrude  through  the  gap,  and  even 
hang  out  from  the  vulva.     The  accident  is  generally  fatal. 

Foreign  Bodies. — The  vagina,  like  the  other  accessible 
cavities  of  the  body,  is  liable  to  have  foreign  bodies  intro- 
duced into  it.  Little  girls  from  sheer  curiosity  insert  hair- 
pins, pebbles,  seeds,  fruit-stones,  pencils,  etc.  Older  girls 
introduce  sponges,  cotton-wool,  and  the  like,  with  the  hope 
of  preventing  conception  from  illicit  intercourse. 

Pomade-pots,  pewter  pots,  cotton-reels  or  spools,  candle- 
extinguishers,  and  small  india-rubber  balls  have  been  re- 
moved from  the  vagina  of  matrons ;  some  of  them  were 
introduced  to  prevent  pregnancy,  others  to  act  as  supports 
to  prolapsed  wombs.  Pessaries  of  extraordinary  shape, 
size,  and  complexity  have  been  introduced  by  obstetric 
physicians  and  forgotten  till  urinary  fistulai  or  stinking  dis- 
charges have  led  to  examination.  Brutal  men  when  rioting 
with  low  drunken  women  have  thrust  into  the  vagina  pipe- 
bowls,  thimbles,  clock-weights,  or  pieces  of  metal. 

The  vagina  has  served  as  a  repository  for  stolen  prop- 
erty— c.  g.  gems,  bank-notes,  jewelry,  and  pocket-books. 

Among  odd  things  the  following  deserve  mention  :  A 
cockchafer  beside  a  pomade-pot  (Schroeder) ;  a  small  bust 
of  Napoleon  the  Great ;  and  cylinders  of  inverted  pork-rind. 
A  woman  was  admitted  into  the  cancer  ward  of  the  Mid- 
dlesex Ho.spital  with  a  certificate  of  "  stone  cancer  "  of  the 


DISEASES   OF   THE    VAGINA.  IO9 

uterus.  Examination  proved  the  alleged  cancer  to  be  a 
piece  of  brick. 

When  a  healthy  young  woman  is  found  to  be  suffering 
from  a  stinking  vaginal  discharge,  it  is  exceedingly  prob- 
able that  she  has  a  foreign  body  in  the  vagina. 

Fistulse. — As  the  vagina  is  placed  between  two  hollow 
viscera,  the  bladder  and  rectum,  it  is  not  surprising  that 
fistulous  passages  are  occasionally  formed  between  them. 
Fistulae  are  caused  by  sloughing  of  the  vagina  during  pro- 
tracted labor;  injuries  from  obstetric  implements;  ulcera- 
tion due  to  pessaries  and  other  foreign  bodies.  They  also 
occur  in  the  late  stages  of  epithelioma  of  the  vagina  and 
carcinoma  of  the  cervix  uteri  and  the  rectum.  Occasion- 
ally they  are  due  to  ulceration  of  the  bladder  set  up  by  ves- 
ical calculi  formed  around  foreign  bodies  introduced  into 
the  bladder. 

Vaginal  fistulae,  vesical,  ureteral,  and  rectal,  occasionally 
follow  vaginal  hysterectomy ;  usually,  however,  they  are 
merely  temporary. 

Vaginal  fistulae  are  of  four  kinds:  i.  Vesico-vaginal ;  2. 
Urethro-vaginal;  3.  Uretero-vaginal;  4.  Recto-vaginal.  The 
names  are  sufficient  to  indicate  their  positions.  Utero-ves- 
ical  fistulae  may  be  also  considered  here. 

Symptoms. — In  the  case  of  a  vesico-vaginal  fistula  the 
patient  complains  that  she  cannot  hold  her  water.  Some 
urine  may  collect  in  the  bladder  and  be  voided  periodically 
if  the  fistula  is  small ;  otherwise  the  urine  escapes  from  the 
vagina  as  rapidly  as  it  enters  the  bladder.  The  vulva  and 
vagina  are  inflamed  and  excoriated  by  the  constant  wetting ; 
and  sometimes  a  phosphatic  incrustation  forms. 

If  the  fistula  be  rectal,  great  discomfort  and  distress  is 
caused  by  the  passage  of  faeces  and  flatus  by  the  vagina  ; 
though,  if  the  fistula  be  small,  the  faeces  may  be  prevented 
by  their  semi-solid  form  from  entering  the  vagina. 

The  Methods  for  the  Detection  of  Vaginal  Fistuhu. — The 
persistent  and  involuntary  escape  of  urine  from  the  vagina  is 


no  diseasilS  of  women. 

sufficient  indication  of  the  existence  of  a  urinary  fistula,  but 
it  is  not  always  a  simple  matter  to  localize  its  precise  position. 

To  determine  this  it  is  advisable  to  put  the  patient  in  the 
lithotomy  position  and  expose  the  parts  with  a  duck-bill 
speculum  introduced  into  the  vagina  in  a  good  light.  A 
vesico-vaginal  or  a  urethro-vaginal  fistula  rarely  gives  rise 
to  difficulty,  and  the  pink  everted  edges  surrounding  its 
vaginal  orifice  soon  lead  to  its  detection.  When  there  is 
difficulty  in  finding  it,  the  vaginal  mucous  membrane  should 
be  cleared  of  mucus,  and  warm  milk  injected  into  the  blad- 
der through  a  catheter  in  the  urethra ;  it  will  then  dribble 
through  the  fistula. 

Injections  of  milk  arc  very  serviceable  for  the  detection 
of  uretero-vaginal  fistulas.  In  this  case  when  it  is  injected 
into  the  bladder  none  escapes  into  the  vagina,  yet  during 
the  course  of  the  examination  urine  has  continued  to  escape 
into  the  vagina.  This  test  is  necessary  even  when  the  ori- 
fice of  the  fistula  is  clearly  visible.  In  this  form  of  fistula, 
if  the  urine  which  escapes  involuntarily  from  the  vagina  is 
collected,  measured,  and  compared  with  that  voided  from 
the  bladder,  it  will  be  found  that  the  two  quantities  equal 
each  other. 

In  the  case  of  a  utero-vesical  fistula  the  urine  will  be 
seen  escaping  from  the  cervical  canal  of  the  uterus ;  when 
milk  is  injected  into  the  bladder  some  of  it  escapes  down 
the  cervical  canal ;  this  is  conclusive. 

Treatment. — In  recent  injuries  the  blood-clot  should  be 
removed  and  deliberate  search  made  for  bleeding  vessels, 
which  should  be  secured  with  forceps  and  ligatured.  Capil- 
lary oozing  is  best  restrained  by  careful  packing  with  gauze. 
The  subsequent  treatment  is  that  adapted  for  wounds  in 
general.  In  the  case  of  foreign  bodies,  they  should  be  re- 
moved as  soon  as  discovered ;  when  long  retained  it  is 
usually  necessary  to  obtain  the  advantage  of  an  ana."s- 
thetic.  Persistent  vaginal  fistuUi.'  of  all  kinds  require  ope- 
rative treatment. 


CHAPTER   XII. 

DISEASES  OF  THE  VAGINA   (Continued). 

VAGINAL    INFECTION    AND    THE    VAGINAL 
SECRETIONS. 

GoNORRHCEA  and  sepsis  play  a  very  important  part  in  the 
production  of  vaginitis.  For  the  better  appreciation  of  their 
influence  we  must  make  some  prehminary  observations  on 
the  bacteriology  of  the  normal  vaginal  and  uterine  secre- 
tions. 

The  Normal  Vaginal  Secretion. — In  the  following 
remarks  the  excellent  account  given  by  Doderlein  will  be 
followed. 

Origin. — The  vagina  contains  no  glands ;  and  some  ob- 
servers have  consequently  inferred  that  the  secretion  found 
in  the  vagina  is  derived  in  every  case  either  from  the  cer- 
vical or  Bartholinian  glands.  This  view  is  disproved  by  the 
following  considerations :  First,  the  cervical  canal  is  nor- 
mally occupied  by  a  tenacious  plug  of  mucus,  which  shuts 
off  the  cervical  from  the  vaginal  canal;  secondly,  the  Bar- 
tholinian glands  usually  secrete  very  little  fluid,  and  the 
ducts  open  on  the  outside  of  the  hymen  ;  thirdly,  in  closed 
vaginal  cysts  a  typical  vaginal  secretion  is  found ;  fourthly, 
the  cervical  and  vaginal  secretions  present  markedly  dif- 
ferent characters. 

The  vaginal  secretion  is  derived  from  the  shedding  of 
squamous  epithelium  together  with  the  exudation  of  some 
lymph-serum.  Normally,  it  forms  a  thin  coating  on  the 
surface  of  the  vagina. 

Characters. — It  is  a  rather  thin  opalescent  fluid,  devoid  of 

111 


1 1 


DJSEASES   OI'    WOMEN. 


visciclit)',  .iiul  soiuctiincs,  when  abundant,  forming  a  wliite 
fliicciilcnt  and  curdy  matter.  It  gives  a  strongly  acid  re- 
action, due  to  the  presence  of  lactic  acid.  Estimated  quan- 
titatively, the  acidity  is  equivalent  to  0.4  per  cent,  of  sul- 
phuric acid  or  0.9  per  cent,  lactic  acid.  In  the  new-born 
the  action  is  neutral ;  in  the  healthy  virgin  it  is  acid ;  in 
normal  pregnancy  the  acidity  is  greater ;  whilst  in  patho- 
logical conditions  the  reaction  is  feebly  acid,  neutral,  or  even 
alkaline.  The  acidity  disappears  during  and  for  some  days 
after  menstruation,  and  for  five  or  six  weeks  after  normal 


Fig.  31. ^Normal  secretion  from  the  vagina,  showing  ilie  vagina-bacillus  (Dodcrlcin). 


labor.  Examined  microscopically,  the  vaginal  secretion  in 
the  new-born  contains  only  squamous  epithelium.  In  the 
virgin  and  in  normal  pregnancy  there  is  constantly  found, 
in  addition,  the  vagina-bacillus  (Figs.  31,  32);  whilst  in  a 
certain  percentage  of  cases  a  fungus  is  found,  the  Monilia 
cajidida.  The  vagina-bacillus  and  the  fungus  are  invariably 
absent  from  pathological  secretions. 

The  vagiiia-bacilliis  belongs  to  the  anaerobic  bacilli.     It 
may  be  cultivated  on  agar  or  gelatin,  or  in  bouillon,  blood- 


DISEASES   OF  THE    VAGINA. 


113 


serum,  or  milk.  It  requires  moisture  and  warmth  equiva- 
lent to  the  body-temperature.  It  occurs  in  the  form  of 
short  straight  rods.  As  the  result  of  pure  cultivations 
lactic  acid  is  invariably  produced,  equivalent  quantitatively 


Fig.  32. — Pure  cultivation  of  vagina-bacillus  (Doderlein). 


to  0.5  per  cent,  sulphuric  acid,  which  corresponds  to  1.125 
per  cent,  lactic  acid. 

Role  of  the  Vagina-bacillus. — To  this  bacillus  is  due  the 
presence  of  lactic  acid  in  the  vaginal  secretion,  as  indicated 
by  the  fact  that  when  the  bacilH  are  absent,  as  in  the  new- 
born and  during  the  puerperium,  the  reaction  of  the  secre- 
tion is  always  neutral.  In  its  presence  saprophytes  and 
pathogenic  micrococci,  such  as  the  streptococcus  and  sta- 
phylococcus, are  unable  to  develop,  and  before  long  perish. 
When  the  vagina-bacillus  is  absent,  as  in  the  lochial  secre- 
tion, both  saprophytes  and  staphylococci  are  able  to  flour- 
ish. The  Monilia  is  a  harmless  organism  which  can  only 
grow  in  the  presence  of  the  vagina-bacillus  ;  that  is,  in  the 
healthy  vaginal  secretion. 

The  antagonism  between  the  vagina-bacillus  and  patho- 


114  DISEASES   OF   WOMEN. 

genie  organisms  is  illustrated  by  the  following  experiments 
described  by  Dodcrlein  : 

(a)  A  pure  cultivation  of  the  vagina-bacillus  on  peptone- 
agar  of  three  days'  growth  was  inoculated  with  a  cultivation 
of  the  staphylococcus  pyogenes  aureus.  The  staphylococci 
were  soon  destroyed.  When,  however,  the  two  bacilli  were 
inoculated  on  agar  at  the  same  time,  the  vagina-bacillus 
perished,  showing  that  abundant  products  of  the  growth  of 
the  latter  arc  required  to  destroy  the  staphylococcus. 

(b)  The  vagina  of  a  virgin  was  inoculated  with  a  bouillon 
culture  of  staphylococcus  pyogenes  aureus.  After  six 
hours  an  abundant  cultivation  of  staphylococci  was  ob- 
tained therefrom.  After  twenty-four  hours  only  a  few 
colonies  were  found;  these  further  diminished  on  the  sec- 
ond and  third  days,  and  by  the  fourth  day  the  staphylo- 
cocci had  been  quite  destroyed  in  the  vaginal  secretion. 

As  a  result  of  the  protective  influence  of  the  vagina- 
bacillus  it  happens,  as  Winter  has  shown,  that  when  patho- 
genic organisms  are  found  in  the  normal  vaginal  secretion 
they  are  always  in  a  condition  of  weakened  virulence. 

The  normal  ccnncal  secretion  consists  almost  entirel}'  of 
mucus,  in  which  are  found  entangled  a  few  columnar  cells 
derived  in  part  from  the  surface  epithelium  and  in  part  from 
that  lining  the  glands.  It  is  in  consequence  viscid  and 
tenacious,  so  that  a  plug  of  it  filling  up  the  external  os  is 
often  very  difficult  to  dislodge.  Its  reaction  is  alkaline  or 
neutral,  and  it  contains  no  micro-organisms. 

Pathological  Vaginal  Secretion. — This  is  thin,  yel- 
lowish white,  or,  if  pus  be  mixed  therewith,  greenish.  It 
may  be  so  abundant  as  to  flow  from  the  closed  vagina,  giv- 
ing all  the  symptoms  characteristic  of  leucorrhoea.  Its 
reaction  varies  from  faintly  acid,  through  neutral,  to 
strongly  alkaline.  Examined  microscopically,  it  is  found 
to  contain  epithelial  debris,  and  often  pus-cells. 

Both  in  cover-glass  preparations  and  by  cultivation  it  is 
found  to  contain   saprophytic   bacilli   and  micrococci — -.viz. 


DISEASES   OF  TJJE    VAGINA. 


115 


staphylococci  and  often  streptococci.  The  vagina-bacillus 
and  the  monilia  fungus  are  never  present. 

A  pathological  vaginal  secretion  may  be  regarded  as 
a  favorable  cultivation  medium  for  pathogenic  organisms. 
Doderlein  performed  eighteen  inoculation  experiments  with 
pathological  vaginal  secretions  on  rabbits,  and  in  every  case 
septicaemia  resulted. 

The  transition  from  a  normal  to  a  pathological  secretion 
may  be  brought  about  in  two  ways  : 

First,  by  mere  functional  increase  in  the  amount  of  secre- 
tion, such  as  arises  from  sexual  excesses.  Thus  in  thirty 
prostitutes  examined  by  Doderlein  the  secretion  was  not 
once  found  to  be  normal,  even  when  there  was  no  specific 
gonorrhoeal  infection.  Masturbation,  the  wearing  of  rubber 
pessaries,  frequent  and  purposeless  vaginal  irrigations,  and 
the  introduction  of  alkaline  substances,  such  as  soap,  may 
have  the  same  effect. 

Second,  through  pathological  organic  changes,  such  as 


Fig.  33. — Gonococci. 


are  found  in  endometritis,  adenomatous  disease  of  the  cer- 
vix, vaginitis,  and  cancer. 

Besides  the  organisms  of  sepsis  there  is  sometimes  found 
a  specific  micro-organism,  the  gonococcus  of  Neisser  (Fig. 


I  1 6  DISEASES   OE   WOMEN. 

2^^-^.  It  must  be  remembered,  hcnvever,  that,  as  Bumm  has 
pointed  out,  the  vagina  often  escapes  gonorrha.'al  infec- 
tion, owing  to  the  resistance  offered  to  the  entrance  of 
gonococci  by  the  stratified  squamous  eiiithelium,  whose 
superficial  portion  is  hard  and  horny.  But  the  disease 
readily  attacks  the  urethra  and  the  delicate  columnar  epi- 
thelium of  the  cervix. 

In  cases  of  gonorrhoea  the  vaginal  secretion  is  therefore 
usually  altered  indirectly  by  the  admi.xture  therewith  of 
the  unhealthy  cervical  secretion,  which  is  abundant,  alka- 
line, purulent,  and  consequently  albuminous ;  and  the 
vaginal  secretion  accordingly  acquires  these  characters. 
The  vagina-bacillus  perishes  under  these  circumstances ; 
and  a  favorable  soil  is  provided  for  the  development  of  the 
pathogenic  germs  previously  described.  The  actual  inocu- 
lation of  these  pathogenic  germs  may  occur  during  men- 
struation, sexual  intercourse,  gynaecological  manipulations, 
and  parturition ;  in  the  latter  case  not  only  through  vaginal 
examinations  and  operative  procedures,  but  also  through 
traumatism  incident  to  labor. 

An  important  practical  deduction  to  be  drawn  from  these 
considerations  is,  that  in  cases  in  which  the  vaginal  secre- 
tion departs  from  the  normal  type  special  care  should  be 
taken  to  disinfect  the  vagina  before  resorting  to  any  intra- 
uterine manipulations,  even  the  passage  of  the  sound,  lest 
the  uterine  cavity,  previously  unaffected,  be  inoculated  with 
septic  organisms. 

Having  thus  briefly  reviewed  the  pathogenesis  of  vag- 
inal infection,  we  may  enumerate  the  principal  morbid 
conditions  which  may  result  therefrom — viz. :  Vaginitis ; 
endometritis,  of  both  cervix  and  body ;  salpingitis,  ca- 
tarrhal and  purulent ;  septic  peritonitis ;  pyocolpos  and 
pyometra ;  and  pelvic  cellulitis.  These  results  may  follow 
either  from  sepsis  alone,  or  from  sepsis  complicated  by 
gonorrhoea. 

In  concluding  these  remarks  on  the  secretions,  the  fol- 


DISEASES   OF   THE    VAGINA.  11/ 

lowing  resume  of  the  different  kinds  of  discharge  found  in 
the  female  genital  passages  may  prove  useful : 

1.  Normal  vaginal  discharge,  of  which  the  characters 
have  been  given  above — viz.  white,  creamy  or  curdy,  and  so 
slight  in  quantity  as  not  to  attract  the  patient's  attention. 

2.  A  clear  viscid  discharge,  composed  principally  of 
mucus.  This  is  the  normal  cervical  discharge,  and  is  usu- 
ally not  seen  except  on  examining  with  the  speculum  ;  but 
it  may  be  mixed  with  the  vaginal  discharges  at  the  begin- 
ning and  end  of  menstruation,  and  occasionally,  when 
abundant,  at  other  times. 

3.  A  muco-purulent  or  purulent  discharge,  yellowish  or 
greenish  according  to  the  proportion  of  pus.  This  is  seen 
characteristically  in  acute  gonorrhoea,  and  commonly  re- 
sults also  from  chronic  endometritis.  It  is  the  variety  most 
frequently  spoken  of  as  "  the  whites,"  when  containing  but 
little  pus.     It  stains  and  stiffens  the  linen. 

4.  Watery  discharges  may  result  from  simple  hyperaemia 
of  the  genital  passages,  and  occasionally  from  intermittent 
hydrosalpinx.  They  are  also  found  in  cases  of  cancer,  but 
the  discharge  then  assumes  more  often  the  characters  of 
the  next  variety. 

5.  Foetid  discharges  occur  as  the  result  of  ulceration, 
and  the  principal  conditions  which  produce  them  are  re- 
tained pessaries,  sloughing  fibro-myomata  and  polypi,  de- 
composing products  of  conception,  and,  most  frequently  of 
all,  cancer. 

6.  Bloody  discharges,  other  than  menstrual,  may  be  due 
to  cancer,  endometritis,  fibro-myomata,  polypi,  adenomatous 
disease  of  the  cervix,  and  lacerations.  The  discharge  is 
often  pinkish  in  cancer ;  but  in  any  of  the  above  con- 
ditions it  may  vary  from  a  very  slight  rose  tint  to  the  red 
of  almost  pure  blood. 


CHAPTER   XIII. 
DISEASES  OF  THE  VAGINA  (Continued). 

INFLAMMATION;  TUMORS  AND  CYSTS. 

Vaginitis. — The  chief  causes  of  inflammation  of  the 
vagina  are — (a)  Injuries,  such  as  result  from  obstetric  ope- 
rations, accident,  foreign  bodies,  retained  pessaries,  immod- 
erate coitus,  and  careless  application  of  caustics  to  the 
uterus ;  (b)  Infections,  such  as  gonorrhcea,  sepsis,  and  tuber- 
culosis ;  and  (c)  Pregnancy. 

According  to  the  age  of  the  patient  different  t}'pes  will 
be  found.  In  children  it  may  be  simple,  or  due  to  thread- 
worms, gonorrh(ea,  and  exceptionally  to  uterine  tubercu- 
losis. In  adults  it  is  nearly  always  gonorrhceal.  Want  of 
cleanliness  and  constitutional  conditions  are  predisposing 
causes,  as  they  favor  the  growth  of  pathogenic  organisms 
(see  preceding  chapter).  It  is  through  a  disturbance  in 
the  secretion,  associated  with  congestion,  that  pregnancy 
may  induce  vaginitis. 

Pathology. — As  in  inflammation  elsewhere,  the  first  con- 
dition is  congestion,  causing  heat  and  redness  of  the  mu- 
cous membrane.  The  discharge  which  is  produced  is 
known  clinically  as  leucorrhca,  and  consists  at  first  of  a 
wateiy  fluid,  with  cast-off  epithelial  cells.  If  the  latter  are 
in  great  quantity,  the  discharge  is  no  longer  clear,  but  white 
and  turbid  (hence  the  name).  If  pus  forms,  it  imparts  a 
yellow  or  green  color  to  the  discharge. 

In  simple  cases  the  inflammation  soon  subsides,  without 
further  change  than  more  or  less  desquamation  of  the  epi- 
thelium.    In   senile  vaginitis  atrophic   changes   follow:   the 

118 


DISEASES   OE   THE    VAGINA.  II9 

epithelium  is  reduced  in  thickness,  and  fibrous  changes 
ensue  in  the  mucous  membrane,  which  narrow  the  hmien 
of  the  passage.  The  same  result  may  occur  in  places  from 
the  action  of  caustics ;  but  here  the  epithelium  may  be 
deeply  destroyed,  and  the  contraction  is  sometimes  marked 
(see  Complications).  When  the  vaginitis  is  purulent,  from 
sepsis  or  gonorrhoea,  on  microscopic  examination  the  epi- 
thelium is  seen  to  be  at  first  swollen,  due  to  infiltration 
of  round  cells  in  the  papillae,  which  are  very  vascular. 
The  interpapillary  spaces  are  filled  up  by  exudation  of  cells 
and  serum,  till  the  papillae  cease  to  be  distinct.  The  epi- 
thelium then  becomes  thin  and  presents  the  appearance  of 
granulations,  which  bleed  readily  (Ruge).  The  gonococcus 
itself  is  not  able  to  penetrate  the  stratified  vaginal  epithe- 
lium (Bumm) ;  but  the  staphylococcus  and  streptococcus 
appear  to  be  able  to  do  so. 

Under  proper  treatment  the  granulations  subside,  and 
the  epithelium  gradually  resumes  its  normal  appearance. 
But  when  the  inflammation  has  been  very  virulent,  large 
patches  of  epitheUum  may  be  detached,  mixed  with  coagu- 
lated exudation ;  and  this  condition  has  been  described  as 
diphtheritic,  membranous,  or  desquamative  vaginitis. 

Varieties. — Clinically  it  is  useful  to  distinguish  the  fol- 
lowing varieties  of  vaginitis  : 

(a)  Vulvo-vaginitis  of  children  ; 

(b)  Vaginitis  of  pregnant  women  ; 

(c)  Gonorrhoeal  vaginitis  of  adults  ; 

(d)  Senile  vaginitis  ; 

(e)  Membranous  vaginitis. 

(a)  Vulvo-vaginitis  of  children  acquires  some  of  its  import- 
ance from  its  medico-legal  bearings.  The  question  of  crim- 
inal assault  sometimes  arises,  and  the  medical  attendant 
should  bear  in  mind  the  following  points :  First,  vulvo- 
vaginitis of  simple  character  may  occur  when  there  has 
been  no  violence  nor  external  interference  of  any  kind.  It 
is  then  found  mostly  in  weak  and  neglected  children.     Sec- 


I20  DISEASES   OE   WOMEN. 

ondly,  vulvo- vaginitis  may  be  produced  by  indecent  vio- 
lence short  of  rape.  Thirdly,  gonorrhceal  vulvo-vaginitis 
may  occur,  in  epidemic  form,  in  schools  ;  the  starting-point 
may  be  an  accidental  contamination  by  the  bed-clothes 
w  hen  children  sleep  with  parents  or  elder  brothers ;  and 
infection  may  be  spread  with  towels  or  other  linen,  or  by 
the  use  of  one  bath  for  several  children.  Fourthly,  the 
gonorrhoea  may  result  from  raj)e ;  this  is  probably  rare 
in  proportion  to  the  total  number  of  cases. 

This  form  of  vaginitis  has  been  found  at  all  ages  from 
early  infancy  to  puberty. 

The  symptoms  are  sometimes  slight ;  with  the  exception 
of  a  mucous  or  purulent  discharge  they  may  be  absent. 
But  more  often  the  child  complains  of  pain,  scalding  mic- 
turition or  itching ;  and  there  may  be  some  febrile  dis- 
turbance. It  has  been  shown  that  thread-worms  may  set 
up  vaginitis  in  children  by  passing  into  the  vagina,  from  the 
rectum.  The  smallness  of  the  hymeneal  orifice  in  children, 
while  it  is  in  some  measure  a  safeguard  against  infection, 
tends  to  aggravate  the  disease  when  once  established,  and 
is  a  difficulty  in  the  way  of  cure,  because  it  favors  the  re- 
tention of  discharges. 

(b)  Vaginitis  of  Pregnant  Women. — To  what  has  been 
said  about  this  we  need  only  add  that  at  times  it  may  be 
due  to  latent  gonorrhoea,  allied  to  gleet  in  the  male,  taking 
on  increased  activity  as  the  result  of  the  congestion  caused 
by  pregnancy. 

Vaginitis  may  occur  also  during  the  puerperium,  as  part 
of  a  puerperal  infection,  and  is  then  generally  septic.  The 
laceration  or  bruising  of  the  vagina  by  the  passage  of  a 
large  head  or  by  instruments  favors  inflammation ;  and 
indeed,  apart  from  infection,  there  is  always  some  degree  of 
traumatic  inflammation  in  these  cases. 

(c,  d,  e)  GonorrJia'al  vaginitis  is  the  most  conmion  form 
of  vaginitis  in  adults,  and  what  is  here  said  of  vaginitis  in 
general  applies   more  especially  to  the   gonorrheeal   foiin. 


DISEASES   OF   THE    VAGINA.  121 

Senile  and  incnibranous  vaginitis  do  not  require  special 
description. 

Symptoms. — The  patient  complains  of  pain  and  burning 
in  the  vulva;  smarting  pain  on  passing  water;  dyspareunia 
and  discharge.  On  examination,  the  vaginal  walls  are  hot, 
red  and  swollen,  and  acutely  tender  to  the  touch.  The  dis- 
charge, generally  yellow  or  green,  is  found  bathing  the  ex- 
ternal genitals  as  well  as  the  vagina.  The  signs  described 
under  the  complications  of  vulvitis  may  also  be  present. 
In  senile  vaginitis  the  discharge  may  be  thin  and  sanious, 
leading  one  at  first  to  suspect  carcinoma  of  the  cervix. 

Diagnosis. — As  stated  under  Vulvitis,  the  matter  of  prin- 
cipal difficulty  and  importance  is  often  to  distinguish  gonor- 
rhceal  from  non-gonorrhceal  vaginitis.  In  the  absence  of 
pus,  the  probability  is  that  the  inflammation  is  of  simple 
character ;  but  in  cases  of  some  standing  this  sign  is  of  less 
importance.  When  there  is  pus  it  may  be  septic  in  origin, 
or  it  may  come  from  the  cervix  uteri,  and  not  primarily 
from  the  vagina.  A  careful  examination  must  therefore  be 
made  with  the  speculum,  when,  if  the  vagina  is  at  fault,  it 
will  be  seen  reddened  and  studded  over  with  brighter  red 
points.  In  all  cases  of  doubt  a  careful  search  must  be 
made  for  gonococci.  Implication  of  the  urethra  and  of  the 
Bartholinian  ducts  affords  strong  presumptive  evidence  of 
gonorrhoea ;  by  some,  either  condition  alone  is  regarded  as 
certain  proof  Leucorrhoea  due  to  endometritis  or  carci- 
noma is  distinguished  from  that  due  to  vaginitis,  by  the  use 
of  the  speculum. 

Course  and  Complications. — If  left  untreated  a  simple 
vaginitis  does  not  give  much  trouble  ;  but  the  results  of 
gonorrhoea  are  far-reaching  and  serious.  The  most  im- 
portant is  the  spreading  of  the  disease  up  the  genital  pas- 
sages, producing  successively  endometritis,  purulent  salpin- 
gitis, and  septic  peritonitis.  For  this  reason  gonorrhoea  is 
a  much  more  serious  condition  in  women  than  in  men. 
Nor  does  the  danger  stop  here.     Under  the  influence  of 


122  DISEASES   OE   WOMEN. 

i)re<^nancy  a  latent  fj^onorrhoL'a  may  reawaken  to  virulent 
activity,  in  the  vagina,  the  uterus,  or  the  tubes ;  or  the 
trouble  may  lie  dormant  till  labor  comes  on,  when  a  rapidly 
fatal  form  of  puerperal  septicemia  may  develop,  for  which 
the  medical  attendant  may  incur  undeserved  responsibility- 
In  other  and  perhaps  more  frequent  cases  sterility  results 
from  the  sealin<^  up  of  the  fimbriated  ends  of  the  Fallopian 
tubes,  which  become  converted  into  bags  of  pus.  This  is 
generally  associated  with  a  troublesome  form  of  dysmenor- 
rhoea.  It  is  evident,  therefore,  that  no  effort  should  be 
spared  to  treat  energetically  and  thoroughly  every  case  of 
acute  gonorrhoeal  vaginitis. 

The  infection  of  the  urethra  seldom  causes  any  complica- 
tions in  women  ;  stricture  is  very  rare,  and  consequently 
the  bladder,  ureters,  and  kidneys  commonly  escape.  At 
times,  however,  cystitis  may  be  set  up. 

In  addition  to  the  complications  mentioned  under  Vulvitis, 
the  following  have  to  be  considered  : 

Vcsico-vaginal  and  Recto-vaginal  Fistiilcs. — These  occur 
more  often  from  other  causes,  but  may  result  also  from 
severe  vaginitis  attended  with  ulceration. 

Atresia  Vagina. — This  is  especially  apt  to  occur  when 
there  has  been  much  destruction  of  the  epithelium,  and  is 
therefore  often  well  marked  when  the  vagina  has  been  much 
injured  by  caustics  applied  to  the  cervix  uteri.  In  such 
cases,  if  examined  at  a  later  date,  the  finger  discovers  the 
vagina  to  be  contracted,  usually  a  little  below  the  level  of 
the  external  os.  The  contraction  may  be  so  great  as  barely 
to  admit  the  finger-tip.  But  if  this  can  be  passed  through 
the  constriction,  which  is  often  annular,  it  enters  an  ex- 
panded part  of  the  vagina,  in  which  is  found  the  cervix. 
The  vagina  may,  in  fact,  be  said  to  present  an  hour-glass 
contraction.  The  condition,  if  it  occur  in  later  midtile  age, 
about  the  time  of  the  menopause,  causes  but  little  trouble ; 
but  in  earlier  adult  life  the  contraction  may  go  on  to  oblit- 
eration of  the  canal,  and  haematocolpos  results.     Similarly, 


DISEASES   OF   THE    VAGINA.  1 23 

but  more  rarely,  the  external  os  may  become  stenosed  or 
occluded,  giving  rise  at  first  to  dysmenorrhoea,  and  later  to 
haimatometra. 

Purulent  oplithalinia  is  a  frequent  complication  of  vulvo- 
vaginitis in  children,  the  infection  being  conveyed  directly 
by  the  patient's  fingers  or  indirectly  through  linen  and 
clothing. 

Peritonitis  ranks  next  in  order  of  frequency  to  ophthalmia 
as  a  complication  of  gonorrhoea  in  young  women. 

GonorrJixal  rJieumatisni  also  occurs,  but  less  frequently 
than  among  men. 

Prognosis. — From  the  above  it  will  be  seen  that  when 
treatment  is  not  thoroughly  carried  out,  the  prognosis  is 
grave  as  regards  the  subsequent  health.  With  proper  care, 
however,  in  the  early  stages,  the  outlook  is  very  satisfactory. 

Treatment. — In  the  treatment  of  simple  vaginitis,  all  that 
is  required  is  to  keep  the  patient  in  bed  and  to  order  vaginal 
douches  of  warm  unirritating  lotions,  such  as  boracic  acid 
(oj  or  3ij  to  the  pint)  or  subacetate  of  lead. 

For  gonorrhoeal  vaginitis,  a  more  energetic  treatment 
must  be  undertaken  in  order  to  abort  the  course  of  the 
disease  and  diminish  the  tendency  to  complications.  The 
following  will  be  found  an  effective  method:  The  patient  is 
anzESthetized  and  placed  in  the  lithotomy  position ;  the 
vagina  is  then  well  irrigated  with  a  solution  of  carbolic  acid 
(i  :  40);  after  which  it  is  thoroughly  swabbed  out  with  a 
solution  of  carbolic  acid  in  glycerin  (i  :  10),  or  with  a  solu- 
tion of  chloride  of  zinc  (10  grs.  to  sj) ;  the  cervix  is  simi- 
larly treated,  and  a  uterine  probe  may  be  dipped  into  the 
solution  and  applied  to  the  uterine  cavity.  The  vagina  is 
then  again  irrigated  with  carbolic  lotion  (i  :  40)  or  a  satu- 
rated solution  of  boracic  acid  ;  iodoform  tampons  are  placed 
in  the  vagina,  and  the  patient  sent  back  to  bed.  The  after- 
treatment  consists  of  douches,  morning  and  evening,  with 
warm  saturated  boracic  lotion. 

If  this  thoroueh  treatment  under  an  ana.'sthetic  cannot 


124  DJSEASKS   OJ-    WOMEN. 

be  applied,  douches  of  carbolic  acid  (i  :  40)  should  be 
ordered  mornini^  and  evening;  it  is  not  advisable  that  much 
force  should  be  used,  lest  toxic  discharges  be  forced  up  into 
the  cervical  canal. 

A  milder  method,  often  serviceable  when  there  is  much 
pain  and  tenderness,  is  a  course  of  hot  sitz-baths,  twice 
daily.  In  children  it  is  advised  that,  in  the  acute  stage,  care 
should  be  taken  that  the  child's  head  be  not  immersed  in 
the  bath,  lest  the  eyes  become  contaminated  by  the  dis- 
charges. After  bathing  or  syringing,  iodoform  bougies 
may  be  placed  in  the  vagina,  each  vaginal  bougie  contain- 
ing 3  grs.  of  iodoform.  For  children  smaller  bougies  are 
employed.  Chronic  vaginitis  is  not  seen  except  in  associa- 
tion with  chronic  endometritis,  and  its  treatment  is  described 
with  that  of  the  latter  condition. 

The  treatment  of  complications  must  be  carried  out  as 
may  be  required. 

An  abscess  in  the  vaginal  xvall  may  be  due  to  extension 
of  pelvic  cellulitis  into  the  connective  tissue  of  the  vagina, 
and  the  abscess-cavity  may  remain  connected  with  that 
from  which  it  is  derived  or  become  cut  off  from  it ;  or  it 
may  be  due  to  suppuration  in  a  vaginal  cyst.  The  febrile 
symptoms  and  the  redness  of  the  vaginal  wall  over  the 
swelling  will  point  to  its  true  nature.  The  treatment  con- 
sists in  evacuating  the  pus  by  means  of  a  free  incision. 

TUMORS  AND  CYSTS  OF  THE  VAGINA. 

The  vagina  is  rarely  the  seat  of  tumors  :  they  belong  to 
four  genera :  lipomata,  myomata,  sarcomata,  and  epitheli- 
oma.    Lipomata  and  myomata  are  v&xy  rare. 

Sarcomata. — Examples  of  this  genus  occur  in  adults; 
it  appears  that  they  are  rare  before  forty  years  of  age. 
They  are  sessile,  ulcerate  early,  and  bleeding  is  the  first 
sign  which  attracts  attention  (Gow).  In  children  the)-  have 
a  tendency  to  be  polypoid.  They  cause  death  by  interfer- 
ing with  the  bladder  or  rectum  (D'Arcy  Power). 


DISEASES   OF   THE    VAGINA.  125 

Bpithelioma. — This  disease  may  arise  in  any  part  of 
the  vaginal  mucous  membrane,  but  it  is  more  liable  to 
begin  at  the  junction  of  the  vulva  and  vagina,  or  on  that 
portion  which  is  reflected  over  the  cervix  uteri.  When 
epithelioma  attacks  the  vulvar  end  of  the  vagina,  it  is  very 
apt  to  begin  near  the  urethral  orifice.  In  such  cases  the 
inguinal  lymph-glands  are  early  infected;  the  ulceration 
quickly  involves  and  perforates  the  vesico-vaginal  septum 
and  leads  to  a  fistula.  When  the  posterior  wall  is  attacked, 
ulceration  leads  to  a  recto-vaginal  fistula. 

It  is  very  extraordinary  that  the  early  .stages  of  this 
fatal  disease  cause  so  very  little  inconvenience  that  patients 
rarely  seek  advice  until  the  disease  has  long  passed  the 
limits  of  justifiable  surgery. 

Cysts. — The  vagina  is  liable  to  the  following  species  : 
mucous,  Gartnerian,  and  peri-urethral  cysts,  and  echino- 
coccus  colonies. 

Mucous  Cysts. — These  are  small  and  resemble  retention 
cysts,  but  their  nature  is  doubtful.  Some  observers  con- 
sider them  as  retention  cysts  of  vaginal  glands ;  others 
deny  the  existence  of  such  glands  and  explain  these  cysts 
as  due  to  obliteration  of  the  mouths  of  crypts  in  the  vaginal 
wall.  By  others,  again,  they  are  regarded  as  due  to  dila- 
tation of  lymphatic  spaces,  and  are  described  as  associated 
with  gaseous  bullae  in  the  condition  called  emphysematous 
vaginitis. 

They  occur  not  infrequently  in  cases  of  vaginitis  and 
endometritis,  resembling  superficially  the  Nabothian  fol- 
licles seen  on  the  cervix. 

Gartnerian  Cysts. — The  pathology  of  these  cysts  is 
described  in  connection  with  the  parovarium. 

Cysts  arising  in  the  terminal  segment  of  this  duct  pro- 
ject as  soft  fluctuating  swellings  in  the  upper  part  of  the 
vagina;  sometimes  two  distinct  cysts  arise  in  connection 
with  one  duct.  They  vary  greatly  in  size ;  some  do  not 
measure  more  than  two  centimetres  in  diameter,  others  may 


126  DISEASES   Of   WOMEN. 

exceed  these  dimensions  three  or  four  times.  The  inner 
wall  of  the  cysts  is  lined  either  with  cubical  or  stratified 
epithelium. 

Peri-urethral  Cysts. — Small  cysts  are  sometimes  found 
in  the  anterior  vaginal  wall  near  the  urethra  :  sometimes  they 
bulge  into  the  urethra.  Skene  is  of  opinion  that  these  cysts 
arise  in  the  ducts  which  he  detected  and  described  in  the 
lloor  of  the  urethra  near  the  meatus. 

Bchinococcus  Colonies  {Hydatids). — These  are  very 
rare  and  are  generally  due  to  echinococcus  colonics  in  the 
mesometrium  burrowing  in  the  recto-vaginal  septum. 

Treatment. — This  is  the  same  as  that  employed  for  tu- 
mors and  cysts  in  other  regions  of  the  body — namely,  re- 
moval— but  in  the  case  of  sarcomata  and  epithelioma  it  is 
rare  for  the  disease  to  come  under  observation  before  it  has 
so  deeply  involved  the  rectal  and  vesical  walls  that  inter- 
ference with  it  only  anticipates  the  complications  which  en- 
sue in  the  natural  course  of  the  disease, — rectal  and  vesical 
fistulae.  Cysts  when  small  are  readily  enucleated,  and  the  pro- 
ceeding is  safe  if  the  operator  keeps  close  to  the  cyst-wall. 
In  the  case  of  large  Gartnerian  cysts  which  burrow  from 
the  vagina  into  the  mespmetrium,  unless  great  care  is  exer- 
cised the  ureter  may  be  easily  damaged  and  a  troublesome 
fistula  result.  When  there  is  difficulty  or  anxiety  in  enu- 
cleating vaginal  cysts,  the  surgeon  may  freely  incise  them, 
evacuate  the  contents,  and  stuff  the  cavity  with  gauze ;  the 
cyst  is  then  slowly  obliterated  by  granulation.  This  method, 
however,  though  safe,  is  rarely  certain,  for  the  rent  in  the 
wall  may  close  and  the  cyst  re-form.  Enucleation  of  the 
whole  of  the  cyst-wall  is  the  only  sure  method  of  treat- 
ment. 


CHAPTER   XIV 


DISEASES  OF  THE  UTERUS. 


AGE-CHANGES;    FLEXIONS    AND    DISPLACE- 
MENTS. 

Age-changes. — The  uterus  undergoes  some  important 
changes  between  birth  and  puberty.  In  the  new-born  in- 
fant the  uterus  has  no  fundus,  its 
summit  is  often  deeply  notched, 
and  the  neck  of  the  uterus  is 
larger  than  its  body.  The  arbor 
vitae  is  very  distinct.  The  body 
of  the  uterus  lies  above  the  level 
of  the  brim  of  the  true  pelvis,  and 
its  anterior  surface  forms  a  well- 
marked  curve  where  it  rests  on 
the  urinary  bladder.  Toward  pu- 
berty the  fundus  develops,  and  the 
organ  assumes  the  pear-like  shape 
so  characteristic  of  the  mature  ute- 
rus (Fig.  34).  After  the  meno- 
pause, it  shares  in  the  general 
atrophy  of  the  reproductive  organs. 
The  cervix  especially  diminishes  in 
size  until  it  becomes  merely  a 
small  button-like  projection  at  the 
inner  end  of  the  vagina. 

Measurements.  —  The   fully- 
developed  virgin   uterus    has    the 
following    average    dimensions:-  length,    3    in.    (7.5    cm.); 
breadth,  2  in.  (5   cm.);    thickness,   i   in.  (2.5   cm.);   length 

127 


Fig.  34. — Sagittal  section  through 
the  uterus  and  the  adjacent  part  of 
the  v.Tgina  of  an  adult ;  J^  natural 
size  (Henle). 


128  DISEASES   OE   WOMEN. 

of  cavity,  2\  in.  (6.2  cm.);  weight  i^  ounces  (42  grammes). 
After  jDregnancy  the  uterus  never  regains  its  virgin  propor- 
tions and  remains,  until  the  menopause,  enlarged  in  all  its 
measurements  and  increased  in  weight. 

FLEXIONS    AND    DISPLACEMENTS    OF    THE 
UTERUS. 

It  has  been  customary  to  include  anteversion  among  the 
displacements  of  the  uterus  ;  as  this  is  the  normal  position 
of  the  uterus,  and  never  gives  rise  to  symptoms,  it  will  be 
omitted  from  the  list  of  pathological  conditions. 

We  have  then  to  consider  the  following :  Anteflexion ; 
Retroflexion  ;  Retroversion  ;  Prolapse  and  Procidentia. 

Anteflexion  of  the  Uterus. — This,  when  moderate,  is 
normal ;  it  becomes  abnormal  when  exaggerated. 

Causes. — It  is  most  often  congenital ;  less  often  it  is  due 
to  parametritis  involving  the  utero-sacral  ligaments.  The 
subsequent  cicatricial  contraction  may  draw  this  portion  of 
the  uterus  backward,  causing  anteflexion. 

Symptoms. — Even  a  considerable  degree  of  anteflexion 
may  exist  without  causing  any  trouble,  especially  in  the 
young.  When  symptoms  are  present  they  are — (i)  dys- 
menorrhoea ;  (2)  sterility ;  (3)  reflex  nervous  phenomena. 
The  way  in  which  dysmenorrhcea  is  produced  is  not  quite 
plain.  It  has  been  attributed  to  obstruction  to  the  outflow 
of  blood  by  the  projecting  angle ;  but  this  is  improbable, 
for  in  the  first  place  the  menstrual  flow  in  these  cases  is 
always  moderate  and  even  scanty,  and  the  amount  of  blood 
passing  at  any  one  time  is  therefore  small ;  and  in  the 
second  place  obstruction  would  necessarily  cause  accumu- 
lation behind  the  obstruction,  and  this  never  occurs.  More 
probably  the  pain  is  caused  by  the  contraction  of  the  muscle 
fibres  at  a  disadvantage.  The  dysmenorrhcea  generally 
comes  on  some  years  after  the  first  establishment  of  men- 
struation. 

Sterility  is  due  partly  to  the  fact  that  congenital  ante- 


DISEASES   OF   THE    UTERUS.  1 29 

flexion  is  generally  associated  with  undcr-dcvelopmcnt  of 
the  uterus,  and  a  pinhole  os  ;  but  it  may  also  result  from 
the  tilting  forward  of  the  cervix ;  for  when  the  canal  is 
straightened  and  the  cervix  points  backward,  conception 
sometimes  follows. 

Reflex  nervous  phenomena  are  not  uncommon ;  one  of 
the  most  frequent  is  bladder-disturbance. 

On  examination  the  fundus  is  felt  like  a  knob  just  in 
front  of  the  cervix,  and  between  the  two  the  tip  of  the  fin- 
ger rests  in  a  well-defined  angle.  The  sound  is  arrested  at 
the  internal  os,  and  in  order  that  it  may  pass  to  the  fundus 
it  may  require  to  be  sharply  bent  forward,  for  the  canal  of 
the  cervix  often  makes  a  right  angle  with  that  of  the  body 
of  the  uterus.  Two  varieties  of  anteflexion  are  found :  in 
one,  the  cervix  is  in  its  normal  position,  whilst  the  fundus  is 
bent  forward  and  downward  (Fig.  35,  III) ;  in  the  other,  the 
fundus  is  in  normal  position,  while  the  cervix  is  bent  for- 
ward and  upward  (Fig.  35,  II). 

Treatvicnt. — Vaginal  pessaries  are  absolutely  useless. 
Two  courses  are  open  :  first,  dilatation  of  the  cervical  canal; 
secondly,  a  plastic  operation.  The  dilatation  should  be 
carried  up  to  12  mm.  It  has  the  effect  of  straightening  the 
canal.  It  may  be  necessary  to  repeat  the  dilatation  after  a 
few  months,  or  to  pass  a  few  smaller  dilators  from  time  to 
time.  In  virgins  these  repeated  manipulations  are  a  disad- 
vantage. Plastic  operations  include  the  division  of  the  cer- 
vix, by  a  single  median  incision  or  bilaterally. 

Retroflexion  of  the  Uterus. — This  occurs,  rarely,  as 
a  congenital  condition ;  more  often  it  is  a  complication  of 
retroversion  (Fig.  35,  V).  In  the  former  condition,  if  the 
fundus  of  the  uterus  be  brought  forward,  for  instance  by 
the  sound,  it  springs  back  into  the  faulty  position  as  soon 
as  the  sound  is  withdrawn.  But  when  associated  with  ret- 
roversion there  is  at  first  free  hinge-like  movement  at  the 
internal  os,  and  the  fundus,  if  replaced,  remains  in  the  new 
position.  If  it  remain  long  retroflexed  this  mobility  be- 
9 


130 


DISEASES   OE   WOMEN. 


comes  impaircti.     The  uterus  sometimes  becomes  fixed  in  a 
position  of  rctroflexiDii  b)'  pelvic  cellulitis. 


II 


III 


\  n        AY 


\  n 


VI 


(^ 


Fig.  35. — Diagrams  illustrating  flexions  and  displacements  of  the  uterus  :  a,  axis  of  the 
vagina;  b,  axis  of  the  normal  uterus  :  I,  nurmal  position  :  II,  anteflexion,  fundus  in  normal 
position;  IH,  anteflexion,  cervix  in  normal  position;  IV,  retroversion;  V,  retroversion 
with  retroflexion;   VI,  anteversion  with  retroflexion  (A.  E.  G.). 

Symptovis. — (i)  Dysmenorrhcea,  produced  in  a  manner 
analogous  to  that  resulting  from  anteflexion.     (2)  Pain  on 


DISEASES   OF   THE    UTERUS.  I31 

defecation,  and  constipation,  due  to  the  pressure  of  the 
fundus  on  the  rectum. 

Sterility  is  not  a  prominent  symptom  of  retroflexion. 

Treatment. — If  the  uterus  be  freely  movable,  as  indicated 
above,  the  flexion  should  be  first  corrected  by  digital 
manipulation,  or  failing  this  by  the  sound,  and  a  Hodge 
pessary  introduced.  Special  care  must  be  taken  lest  the 
uterus  be  brought  into  a  position  of  anteversion  while 
the  flexion  remains  unreduced  (Fig.  35,  VI).  The  posi- 
tion of  the  cervix  must  accordingly  not  be  taken  as  a 
guide,  but  the  fundus  must  be  felt  bimanually  in  front 
of  the  cervix. 

If  the  uterus  be  rigid,  a  Hodge  pessary  will  not  correct 
the  flexion  ;  dilatation  of  the  cervix  is  then  the  proper 
treatment,  and  a  Hodge  pessary  may  be  subsequently 
applied,  or  a  plastic  operation  may  be  undertaken,  such 
as  hysteropexy. 

Retroversion  of  the  Uterus. — Retroversion  of  a  nor- 
mal-sized uterus  is,  under  certain  circumstances,  physiologi- 
cal ;  for  instance,  in  a  patient  lying  on  her  back  with  a  full 
bladder.  In  such  a  case  it  is  not  an  uncommon  thing  to 
find,  on  making  a  second  examination  a  few  days  later,  that 
the  fundus  is  lying  forward.  The  same  thing  may  occur 
with  a  uterus  that  is  slightly  enlarged,  as  in  early  preg- 
nancy, and  during  the  early  weeks  after  labor.  These  con- 
ditions, therefore,  require  no  treatment.  In  other  cases 
retroversion  is  a  pathological  condition. 

Causes. —  I.  Relaxation  of  the  uterine  ligaments,  as  the 
effect  of  repeated  pregnancy.  The  utero-sacral,  round,  and 
broad  ligaments  are  all  involved,  for  if  any  one  pair  of  the 
three  retained  its  normal  tension,  retroversion  would  be 
resisted. 

2.  Increased  weight  of  the  fundus,  due  to  chronic  con- 
gestion, subinvolution,  pregnancy,  or  myomata. 

3.  Cicatricial  contraction  following  pelvic  inflammation  ; 
such  as  shortenincf  of  the  utero-sacral  ligaments  when  the 


132  DISEASES   OF   WOMEN. 

round  ligaments  are  relaxed.     If  these  remain  tense,  ante- 
flexion is  produced  instead. 

4.  Pressure  on  the  front  of  the  uterus,  due  to  an  ovarian 
or  other  tumor,  or  to  a  frequently  over-distended  bladder. 
A  wandering  spleen  lodged  in  the  pelvis  has  sometimes 
caused  the  same  result. 

5.  Retroversion  is  in  rare  cases  due  to  a  fall  or  sudden 
strain  ;  it  is  a  question  whether  this  cause  can  operate  with- 
out the  predisposition  indicated  under  paragraphs  i  and  2. 

Symptoms. — These  vary  according  as  the  retroversion  is 
simple  or  complicated  by  pelvic  inflammation  or  fixation. 
Among  the  symptoms  caused  by  a  movable  retroverted  ute- 
rus, there  may  be  sudden  pain,  if  the  displacement  has  been 
accidentally  produced  ;  otherwise  the  patient  complains  of  a 
feeling  of  ill-defined  weight  and  fulness  in  the  pelvis,  due, 
probably,  to  congestion.  From  the  position  of  the  fundus 
there  is  often  discomfort  during  action  of  the  bowels,  and  con- 
stipation. Bladder  disturbance  is  not  common  unless  the 
uterus  is  enlarged;  aud  then  there  may  be  enough  pressure 
of  the  tilted  cervix  against  the  base  of  the  bladder  to  cause 
frequent  desire  for  micturition  with  dysuria;  followed  by 
complete  retention  of  urine.  If  the  fundus  remains  for  some 
time  low  in  the  recto-vaginal  (Douglas's)  pouch,  the  tubes 
and  ovaries  are  dragged  upon,  and  one  or  both  of  the  latter 
may  become  "  prolapsed  ;"  in  that  case  dyspareunia  is  gen- 
erally complained  of,  as  well  as  dysmenorrhcea,  and  ster- 
ility is  usually  present. 

When  complicated  with  pelvic  inflammation,  the  chief 
symptoms  are — pain,  often  excessive  and  continuous;  se- 
vere dysmenorrhcea ;  irregular  metrorrhagia,  due  to  the 
fact  that  the  uterus  cannot  contract  properly ;  abundant 
leucorrhoea,  caused  by  the  pelvic  congestion ;  general 
weakness,  and  secondaiy  nervous  disturbances. 

The  reflex  nervous  disorders  consequent  on  retroversion 
and  retroflexion  (for  the  two  conditions  are  frequently  com- 
bined) require  some  notice.     A  list  of  them  would  com- 


DISEASES   OF   THE    UTERUS.  1 33 

prise  all  known  functional  disorders  ;  and,  while  the  associa- 
tion of  some  of  these  with  displacement  may  be  considered 
as  a  coincidence,  tiiere  are  many  which  must  be  regarded 
as  directly  due  to  the  uterine  condition,  as  is  shown  by 
those  cases  in  which  reposition  of  the  uterus  is  followed  by 
immediate  cessation  of  symptoms,  whilst  these  come  on 
again  at  once  if  the  displacement  recurs.  The  most  fre- 
quent reflex  neuroses  are — digestive  disorders,  especially 
vomiting ;  cardiac  disturbances ;  frequency  of  micturition 
and  incontinence  of  urine ;  headache  and  neuralgia.  In 
some  cases  of  long  standing,  the  restoration  of  the  uterus 
to  its  proper  position  is  not  followed  by  improvement  of  the 
reflex  disorders  ;  although  the  first  appearance  of  these  may 
have  coincided  with  the  commencement  of  the  uterine  trouble. 

Complications. — Among  these  we  might  reckon  the  ner- 
vous disturbances  just  referred  to.  The  local  complications 
include  pelvic  inflammation,  prolapse  of  the  ovaries  and 
tubes,  and  hernia  of  the  pelvic  floor, — namely,  cystocele, 
rectocele,  and  prolapse  of  the  uterus.  As  we  shall  point 
out  in  discussing  prolapse,  retroversion  of  the  uterus  is 
nearly  always  the  first  stage  in  the  production  of  that 
condition. 

Treatment. — The  first  thing  is  to  replace  the  uterus,  with 
the  fingers  alone  if  possible ;  with  the  sound  if  necessary. 

Digital  Manipnlation. — Two  fingers  are  introduced  into 
the  vagina  and  are  made  to  press  on  the  fundus,  through 
the  posterior  vaginal  fornix,  in  a  direction  forward  and  up- 
ward. If  the  uterus  be  fairly  rigid  the  fundus  can  readily 
be  tilted  up  by  pressing  backward  on  the  front  of  the  cer- 
vix. The  fundus  being  raised  by  either  method,  the  fingers 
of  the  other  hand  depress  the  abdominal  wall  above  the 
uterus  and  bring  the  fundus  forward,  whilst  the  fingers  in 
the  vagina  assist  by  pressing  the  cervix  back.  The  manip- 
ulation may  be  assisted  by  placing  the  patient  in  the  genu- 
pectoral  position  ;  and  in  difficult  cases,  when  the  use  of 
the  sound  is   contraindicated,  this  should  be  done. 


134  DISEASES   OF   WOMEN. 

Replaccuioit  ivith  the  Sound. — The  sound  is  passed  with 
the  concavity  of  the  curve  pointing  backward.  When 
the  point  is  at  the  fundus,  the  handle  is  brought  round  to 
the  front  with  a  wide  sweep,  so  that  its  intra-uterine  portion 
rotates  on  its  longitudinal  axis,  but  does  not  otherwise 
move.  On  no  account  should  the  semicircle  described  by 
the  revolving  portion  be  made  by  the  point  of  the  sound. 
The  handle  is  then  gently  and  slowly  drawn  backward,  in 
the  middle  line,  toward  the  perineum,  until  the  fundus  can 
be  felt  with  the  hand  on  the  abdomen.  While  the  sound  is 
being  withdrawn,  the  finger  in  the  vagina  should  be  pressed 
against  the  cervix,  to  keep  it  in  position. 

The  uterus  having  been  replaced,  some  form  of  Hodge 
pessary  is  then  introduced,  paying  attention  to  several 
points.  Thus  the  instrument  must  fit  properly;  it  must 
be  adapted  to  the  width  of  the  posterior  fornix,  and 
also  to  the  length  of  the  vagina.  If  too  long,  it  is  apt  to 
press  on  the  urethra,  and  cause  difficulty  in  micturition ;  or 
it  may  press  on  the  rectum  and  produce  a  tendency  to  con- 
stipation. If  the  vaginal  walls  are  lax  and  the  fundus 
heavy,  the  instrument  is  likely  to  be  tilted  up  anteriorly, 
and  the  retroversion  is  reproduced.  If  an  ovary  is  lying  in 
the  recto-vaginal  (Douglas's)  pouch  it  may  be  pressed  upon, 
and  much  pain  will  result.  An  instrument  made  of  block 
tin  answers  well ;  it  is  clean,  and  can  be  moulded  to  any 
desired  shape.  One  or  both  of  the  posterior  angles  can  be 
depressed  to  prevent  pressure  on  the  ovaries,  and  the  an- 
terior bar  may  be  indented  so  as  to  form  an  arch  over  the 
urethra.  The  relation  of  the  breadth  to  the  length  of  the 
instrument  can  also  be  adjusted.  As  a  rule  the  posterior 
bar  should  be  made  to  project  well  forward  and  upward. 

When  adhesions  are  present,  treatment  must  be  different. 
Obviously,  to  put  in  a  pessary  is  to  add  risk  to  ineffi- 
ciency. The  one  thing  needful  is  to  restore  the  mobility  of 
the  uterus.  If  time  be  no  object,  this  may  often  be  attained 
by  a  somewhat  prolonged  course  of  rest  in  bed,  combined 


DISEASES   OF   THE    UTERUS.  1 35 

with  a  depletory  treatment  by  means  of  vaginal  irrigation 
and  tampons  of  glycerin,  with  or  without  ichthyol  (5  to  10  per 
cent.).  During  this  treatment  an  occasional  attempt  must 
be  made  to  raise  up  the  uterus ;  for  this  purpose  the  sound 
may  be  used,  but  it  requires  to  be  employed  with  great 
care.  After  some  time  it  will  often  be  found  that  the  uterus 
can  be  moved  a  little,  and  by  degrees  the  normal  position 
can  be  restored.  When  this  occurs  a  Hodge  pessary  is  in- 
troduced and  kept  in  for  some  time. 

If  suppurative  disease  of  the  appendages  be  present,  the 
above  treatment  will  generally  be  futile ;  and  until  the  of- 
fending organs  be  removed  no  permanent  cure  can  be  hoped 
for. 

Sometimes  the  adhesions,  by  long  neglect,  have  become 
so  firm  that  they  cannot  be  overcome  by  the  above  means. 
An  operation  then  gives  the  only  hope  of  cure — namely, 
opening  the  abdomen,  freeing  the  adhesions,  and  suturing 
the  fundus  to  the  abdominal  wall  (hysteropexy).  This 
should  not  be  lightly  undertaken,  but  the  risk  attending  it 
should  be  carefully  weighed  with  the  alternative  of  not 
operating,  which  may  mean  a  life  of  chronic  invalidism  and 
impaired  usefulness, 

Even  when  there  are  no  adhesions,  pessaries  may,  after 
long  trial,  entirely  fail  to  relieve  the  retroversion  and  the 
attendant  symptoms ;  and  here  also  operative  interference 
may  be  required.  Hysteropexy  and  the  operation  for 
shortening  the  round  ligaments  are  the  two  principal 
methods  of  dealing  with  this  condition. 


CHAPTER   XV. 

DISEASES  OF  THE  UTERUS  (Continued). 

PROLAPSE  AND  PROCIDENTIA;  HYPERTRO- 
PHY AND  ATROPHY  OF  THE  UTERUS. 

The  terms  prolapse  and  procidentia  arc  applied  to 
different  degrees  of  the  same  condition  :  when  the  uterus, 
though  low  down,  lies  entirely  in  the  va(;ina,  it  is  spoken 
of  as  prolapse  ;  when  it  protrudes  through  the  vulva,  as 
procidentia. 

Causes. — All  the  causes  of  retroversion  of  the  uterus, 
except  cicatrical  contraction  due  to  pelvic  inflammation, 
may  be  regarded  as  predisposing  to  prolapse,  inasmuch  as 
the  former  is  the  first  stage  of  the  latter.  The  exciting 
causes  are — 

1.  Increased  intra-abdominal  pressure,  either  continuous, 
as  in  the  case  of  ascites  and  abdominal  tumors,  or  inter- 
mittent, as  from  frequent  straining  efforts  or  a  chronic 
cough. 

2.  Weakening  of  the  supporting  structures  of  the  pelvic 
floor,  such  as  relaxation  and  hypertrophy  of  the  v^aginal 
walls  and  laceration  of  the  perineum.  A  very  patulous  con- 
dition of  the  vulva,  such  as  is  met  with  sometimes  in  mul- 
tiparas, may  have  the  same  effect  as  a  damaged  perineum. 

3.  Traction  on  the  uterus  from  below,  by  the  weight  of  a 
hypertrophied  cervix,  by  a  cervical  tumor,  or  by  repeated 
operative  manipulations,  whereby  the  uterus  is  drawn  down. 

Pathology. — It  occasionally  happens,  when  the  pelvis  is 
large  and  the  vaginal  walls  are  very  lax,  that  the  uterus 
becomes  prolapsed  in  a  position  of  anteversion  ;  but  this  is 

136 


DISEASES   OF   THE    UTERUS.  1 37 

rare.  The  uterine  canal  is  normally  at  risj^ht  angles  to  the 
vagina,  and  in  the  great  majority  of  cases  the  uterus  must 
come  to  lie  in  the  axis  of  the  pelvic  outlet  before  prolapse 
can  occur  to  any  extent.  As  long  as  it  lies  in  the  axis  of 
the  pelvic  inlet,  deficiency  of  the  pelvic  floor  has  no  appre- 
ciable effect,  and  intra-abdominal  pressure  simply  presses 
the  whole  uterus  backward  against  the  posterior  vaginal 
wall  and  the  sacrum.  But,  once  retroversion  takes  place, 
the  lack  of  perineal  support  is  felt,  and  increased  pressure 
leads  to  descent  of  the  uterus  toward  the  vaginal  orifice. 
The  mechanism  presents  a  close  parallel  to  the  delivery  of 
the  head  during  parturition  in  the  unreduced  occipito-pos- 
terior  position  :  the  long  axis  of  the  head  does  not  conform 
to  that  of  the  pelvic  outlet,  and  delivery  is  delayed ;  whilst 
as  soon  as  rotation  forward  of  the  occiput  places  the  long 
axis  of  the  head  in  relation  to  that  of  the  pelvic  outlet, 
descent  is  easy. 

As  the  uterus  descends,  it  draws  down  with  it  the  upper 
part  of  the  vaginal  walls,  whereby  the  vaginal  fornices  are 
deepened.  If  the  initial  causes  remain  at  work,  and  the 
vaginal  orifice  be  large,  either  from  stretching  or  from 
deficiency  of  the  perineum,  the  cervix  protrudes  from  the 
vulva  (Fig.  36),  and  eventually  the  greater  portion  or  the 
whole  of  the  uterus  comes  to  lie  outside,  covered  by  the 
vaginal  walls  reflected  over  it.  In  this  way  a  mass  the  size 
of  the  closed  fist  may  be  found  outside  the  vulva. 

When  the  whole  vaginal  attachment  is  very  lax,  the 
lower  portion  of  the  vaginal  walls  may  take  part  in  the  pro- 
trusion, in  the  form  of  a  cystocele  and  rectocele ;  whilst  in 
exceptional  cases  the  tubes  and  ovaries,  the  bladder,  and  a 
considerable  portion  of  the  intestines  may  come  to  lie  in 
the  hernial  mass. 

There  is  another  mode  of  production  of  prolapse  in  which 
descent  of  the  whole  uterus  is  not  the  principal  feature  ;  but 
the  first  stage  is  hypertrophy  of  the  supravaginal  portion 
of  the  cervix — /.  c.  the  part  situated  between  the  internal  os 


138 


DISEASES   OF   WOMEN. 


aiul  the  wiL^inal  portion.  In  the  course  of  the  hypertrophic 
elongation,  either  the  fundus  must  be  pushed  upward  or 
the  vaginal  portion  downward.  The  latter  is  the  course  of 
least  resistance,  and  is  consequently  followed.  In  these 
cases  the  cervix  may  be  low  down,  while  the  fundus  is 
nearly  in  its  normal  position  and  the  uterine  cavity  is  found 
to  be  greatly  lengthened  (Fig.  37).  Later  the  whole  uterus 
may  assume  a  lower  position  as  the  result  of  the  increasing 


Fig.  36. — Prolapse  of  uterus  due  to  the  pressure  of  two  ovarian  dermoids. 


weight  of  the  cervix.  Authors  differ  in  the  relative  influ- 
ence which  they  ascribe  to  these  two  conditions,  primary 
descent  and  hypertrophy,  in  the  production  of  prolapse; 
the  difference  is  no  doubt  partly  due  to  the  fact  that  in 
cases  of  primary  descent  a  certain  degree  of  secondary 
hypertrophy  generally  occurs.  We  believe  that  primary 
descent  is  the  more  frequent  condition. 

Rcsiilis  of  Prolapse  and  Procidentia. —  The  continued  re- 


DISEASES   OF   THE    UTERUS.  1 39 

troversion  leads  to  chronic  congestion  and  hyperplasia  of 
the  whole  uterus  ;  but  the  effect  is  most  marked  in  the 
cervix,  which  is  less  supported  by  surroundinij  structures 
and  more  exposed  to  the  influences  leading  to  chronic  in- 
flammation. We  find,  therefore,  chronic  cervical  catarrh 
and  cervical  hypertrophy  in  the  majority  of  cases,  whilst 
adenomatous  disease  is  frequent. 

In  cases  of  procidentia  the  cervix  is  greatly  thickened. 
By  the  rubbing  of  the  clothes  and  exposure  to  the  air  the 
exposed  surface  of  the  vagina  and  cervix  is  hardened  and 
thickened,  so  that  it  comes  to  resemble  skin,  and  patches 
of  ulceration  are  not  uncommon.  These  may  attain  the 
size  of  a  florin  ;  they  have  a  clean,  punched-out  appearance  ; 
the  base  and  margins  are  smooth  and  the  latter  are  neither 
raised  nor  undermined.  When  the  protrusion  has  been  re- 
duced and  kept  in  position  for  some  time,  the  hardened  sur- 
face becomes  moist  and  soft  again,  returning  to  its  normal 
condition. 

Signs  and  Symptoms. — The  patient  complains  of  a  feel- 
ing of  "bearing  down;"  of  trouble  with  micturition  and 
defecation ;  of  pain  and  fatigue  in  walking ;  and  of  "  falling 
of  the  womb."  When  the  uterus  is  low  down,  but  still  con- 
fined within  the  vagina,  the  symptoms  are  often  more  severe 
than  in  procidentia ;  indeed,  it  is  not  uncommon  to  meet  with 
patients  who  have  been  going  about  their  work  for  a  consid- 
erable time  with  a  large  mass  protruding  from  the  vulva. 
The  signs  are  generally  obvious.  In  the  milder  cases  the 
cervix  is  felt  to  be  low  down  in  the  vagina,  the  uterus  being 
in  a  position  of  retroversion.  The  sound  shows  that  the 
uterine  cavity  is  lengthened,  and  the  amount  of  lengthening 
will  afford  information  as  to  the  degree  of  hj'pertroph}'  in 
the  case.  A  rectal  examination  will  complete  the  informa- 
tion ;  for  when  there  is  not  much  hypertrophy  the  level  of 
the  fundus  will  be  easily  reached  by  the  finger,  whilst  in 
cases  of  considerable  hypertrophy  the  fundus  may  in  this 
manner  be  felt  to  occu[))'  nearly   its  normal  position. 


140  DISEASES   OF   WOMEN. 

Procidentia  is  evident  on  inspection.  The  external  os 
will  be  found  usually  on  the  most  prominent  part  of  the 
mass,  and  occasionally  in  front  of  or  beliind  this  point  when 
the  case  is  complicated  by  a  large  rectocele  or  cystocele. 

Diagnosis. — This  is  easy  ;  but  procidentia  may  be  sim- 
ulated by  inversion  of  the  uterus.  Here  the  surface  is 
redder  and  softer,  and  instead  of  the  central  orifice  of  the 
external  os  the  two  lateral  orifices  of  the  Fallopian  tubes 
are  seen.  A  large  polypus  may  at  first  sight  be  mistaken 
for  procidentia,  but  the  absence  of  an  orifice  and  the 
presence  of  a  pedicle  leading  up  to  the  cervix  will  establish 
the  diagnosis.  It  is  important  to  determine  whether  the 
case  is  one  of  simple  descent  or  of  hypertrophy  of  the 
supravaginal  cervix,  as  the  treatment  is  different ;  this  may 
be  done  as  above  mentioned  under  the  head  of  physical 
signs.  It  should  be  ascertained  also  whether  there  is  any 
cause  for  the  prolapse  beyond  deficiency  of  the  pelvic 
floor  and  relaxation  of  ligaments;  so  that,  if  found,  this 
may  be  dealt  with. 

Treatment. — A  prolapsed  uterus  must  first  be  placed  in 
proper  position,  or  a  procidentia  reduced.  In  many  cases 
the  introduction  of  a  rubber  ring  pessary'  will  then  suffice 
to  prevent  recurrence.  But  it  will  often  be  found  necessary 
to  repair  a  torn  perineum,  removing  at  the  same  time  re- 
dundant portions  of  the  vaginal  walls,  before  the  ring  will 
remain  in  the  vagina.  When  such  an  operation  is  contra- 
indicated,  and  the  vaginal  orifice  is  so  wide  that  a  ring  can- 
not be  kept  in,  some  form  of  pessary  with  a  vaginal  stem 
and  perineal  bands  will  be  required  (see  Chapter  XVI.). 

In  cases  of  procidentia  where  the  exposed  surface  is 
much  ulcerated,  the  patient  should  he  kept  in  bed,  emollient 
ajjplications  made  to  the  ulcers,  and  vaginal  douches  given. 
When  the  ulcers  have  healed  a  pessary  may  be  introduced- 
The  congestion  usually  requires  no  special  treatment,  as  it 
subsides  when  the  uterus  is  maintained  in  a  normal  position. 

Procidentia  due  to  supravaginal  li)'pertrophy  of  the  cer- 


DISEASES   OF   THE    UTERUS.  14I 

vix  must  be  differently  dealt  with :  here  complete  reduc- 
tion is  not  possible,  as  even  when  the  fundus  is  in  normal 
position  the  cervix  is  low  down.  Amputation  of  a  por- 
tion of  the  cervix  must  therefore  form  the  first  step  in 
the  treatment;  and  it  may  be  required  also  when  the 
hypertrophy  is  secondary  to  descent.  Cases  of  prolapse 
and  procidentia  which  resist  milder  measures  require  further 
operative  procedures,  such  as  ventro-fixation  of  the  uterus 
or  the  shortening  of  the  round  ligaments.  It  is  in  cases  of 
this  kind  that  hysteropexy  has  often  given  the  most  brilliant 
and  satisfactory  results. 

Alexander's  operation  succeeds,  not  by  pulling  up  the 
uterus,  but  by  maintaining  the  fundus  in  a  position  of  ante- 
version.  The  first  stage  in  prolapse,  retroversion,  being  thus 
prevented,  the  prolapse  itself  is  prevented.  If  the  shorten- 
ing be  not  sufficient  to  cause  anteversion,  it  is  useless ;  for 
the  fundus  is  then  able  to  move  freely  along  an  arc  of  a 
circle  whose  radius  is  determined  by  the  length  of  the  round 
ligaments,  and  whose  centre  is  at  the  symphysis.  The  arc 
corresponds  closely  to  the  pelvic  axis. 

Total  extirpation  of  the  uterus  has  been  advised  and 
practised  for  the  treatment  of  procidentia.  The  operation 
is  under  the  circumstances  singularly  easy,  but  the  ques- 
tion of  the  justifiability  of  so  radical  a  measure  is  an  im- 
portant one. 

HYPERTROPHY  OF  THE  CERVIX  UTERI. 

This  presents  two  varieties  according  as  the  supravaginal 
or  vaginal  portion  of  the  cervix  is  affected. 

Hypertrophy  of  the  Supravaginal  Portion. — This 
may  occur  as  a  primary  or  secondary  condition. 

When  primary  it  may  in  some  cases  be  inflammatory  in 
its  origin,  and  some  authors  have  supposed  it  to  be  so  in 
every  case.  But  we  think  it  doubtful  whether  metritis  often 
has  this  effect,  and  prefer  to  regard  the  origin  as  unex- 
plained.    Specimens    examined  after   removal  have    some- 


142 


D/SE.ISES   OF   WOMEN. 


limes  presented  the  appearances  of  parenchymatous  metri- 
tis ;  but  this  may  have  occurred  as  a  secondary  change.  In 
other  cases  the  structure  has  been  that  of  the  normal  cervix. 

The  effect  of  this  hypertro[)hy  lias  been  described  in  the 
section  on  Prolapse  of  the  Uterus.  The  fundus  remains  in 
its  normal  j)osition,  while  the  cervix  is  found  low  d(jwn  in 
the  \'ai;ina  or  protruding  from  the  vulva. 

When  secondary  it  is  the  result  of  prolapse  (Fig.  37), 
and   is  most  likel}'  to  occur  when  the  latter  is  caused  by 


'Ric/um 


Uterus. 


Bladder. 


Fig.  37. — Ulenis.  bladder,  and  rectum  in  .s.-»gittal  section  ;  from  a  ca.se  of  hypertrophy  of 
tlie  supravaginal  section  (Museum  R.  C.  Surgeons). 


traction  from  below  while  the  fundus  is  partly  anchored  by 
adhesions  ;    but  the  congestion  of  a  prolap.sed    uterus  no 
doubt  plays  a  part  in  the  production  of  hypertrojihy. 
Whether  the  hypertrophy  be  primary  or  secondary,  the 


DISEASES   OF   THE    UTERUS.  I43 

resulting  condition  is  the  same.  The  cervical  portion  of 
the  uterine  canal  is  elongated.  The  vaginal  portion  of  the 
cervix  retains  its  proper  length,  or  may  be  slightly  elon- 
gated ;  but  a  false  appearance  of  great  lengthening  is  pro- 
duced by  the  dragging  down  of  the  vaginal  fornices  by  the 


Fig.  38. — Two  diagrams  illustrating  (A)  hypertrophy  of  the  supravaginal  portion,  and 
(B)  hypertrophy  of  the  vaginal  portion  of  the  cervix :  a,  bladder;  3,  recto-vaginal  pouch; 
c,  vagina  (A.  E.  G.). 

cervix  as  it  descends  (Fig.  38,  a).  For  the  same  reason  the 
vagina  is  always  shortened. 

The  symptoms  and  physical  signs  are  those  of  prolapse. 
The  proper  treatment  is  amputation  of  the  cervix. 

Owing  to  the  close  attachment  of  the  bladder  to  the 
anterior  surface  of  the  uterus,  it  remains  in  front  of  the  cer- 
vix as  it  lengthens  ;  and  a  sound  introduced  into  the  bladder 
may  be  felt  to  pass  down  apparently  in  the  substance  of 
the  anterior  part  of  the  cervix.  Similarly,  the  peritoneum 
is  closely  connected  with  the  posterior  surface,  and  the 
rectovaginal  (Douglas's)  fossa  becomes  deepened  when  the 


144 


DISEASES   OF   WOMEN. 


cervix  lengthens,  so  that  a  process  of  peritoneum  may  be 
found  under  the  vaginal  reflection  on  the  posterior  surface 
of  the  cervix.  These  facts  require  to  be  borne  in  mind  in 
amputation  of  the  cervix,  lest  the  bladder  be  injured.  The 
opening  of  the  coelom  (peritoneal  cavityj  is  less  serious,  and 
is  perhaps  in  most  cases  unavoidable. 

A  distinction  is  made  by  many  Continental  writers  be- 
tween hypertrophy  of  the  supravaginal  portion  proper,  and 

the  part  which  they  describe  as 
the  intermediate  portion  (Fig. 
39).  The  former  is  said  to  cause 
obliteration  of  both  vaginal  for- 
nices  (Fig.  37),  whilst  in  the  lat- 
ter variety  the  posterior  fornix  is 
preserved  (Schroeder).  In  the 
form  which  we  are  now  about  to 
describe  both  forniccs  remain. 

Hypertrophy  of  the  Vagi- 
nal Portion  of  the  Cervix. — 
This  is  often  spoken  of  as  the 
i)ifravaginal  portion  ;  the  above 
term  is  more  correct.  A  small 
degree  of  In-pertrophy  often  oc- 
curs, as  previously  stated,  in  connection  with  chronic  cer- 
vical catarrh  and  erosion  ;  the  enlargement  is  then  more 
strictly  speaking  due  to  inflammatory  infiltration,  with 
thickening  of  the  glandular  tissues,  and  we  need  not  dwell 
on  it  further. 

Hypertrophy  proper  is  a  developmental  or  congenital 
condition,  but  it  is  described  here  instead  of  in  the  chapter 
on  Malformations  for  convenience  and  for  the  sake  of  com- 
parison with  the  previous  condition.  The  growth  takes 
place  principally  at  the  time  of  puberty,  and  nothing  is 
known  as  to  its  causation.  It  is  generally  associated  with 
stenosis  of  the  external  os,  which  presents  the  "  pinhole  " 
type.     The  elongation   may  be  so  great  that  the   cervix 


Fig.  39. — Diagram  of  the  three 
zones  of  the  uterine  neck  (Schroeder)  : 
a,  infravaginal  portion  ;  b,  intermedi- 
ate portion  ;  c,  supravaginal  portion. 


DISEASES   OF   THE    UTERUS. 


H5 


protrudes  through  the  hymen.  The  vaginal  reflection  is 
attached  to  the  base  instead  of  near  the  apex  of  the  hyper- 
trophied  portion,  and  consequently  the  length  of  the  vagina 
is  not  diminished  (Figs.  38,  B,  and  40).  This  serves  as  a 
striking  distinguishing  feature  between  this  and  the  form 
of  hypertrophy  previously  described.  The  bladder  and 
recto-vaginal  pouch  retain  their  normal  positions  and  thus 


Fig.  40. — A  prolapsed  uterus  in  sagittal  section. 


diminish  risk  of  either  being  wounded  during  the  opera- 
tion of  amputation. 

The  symptoms  to  which  it  gives  rise  are  a  sense  of  dis- 
comfort and  the  feeling  of  a  foreign  body  in  the  vagina ; 
sometimes  it  causes  dysmenorrhcea,  menorrhagia,  and  leu- 
corrhcea.  But  in  some  cases,  if  the  cervix  remains  within 
the  vagina,  no  symptoms  may  be  complained  of  till  after 
10 


146  DISEASES   OF   WOMEN. 

niarriaj:^c,  when  it  <;ivcs  rise  to  dysparcuiiia.  The  diagnosis 
is  a  matter  of  no  difficulty  when  the  len^^th  of  the  vagina 
has  been  ascertained.  The  only  possible  treatment  is  am- 
putation of  the  cervix. 

ATROPHY  OF  THE  UTERUS. 

Atrophy  occurs  normally  after  the  menopause,  and  may 
proceed  to  such  an  extent  that  the  cervix  entirely  disap- 
pears, leaving  only  a  small  aperture  in  the  vaginal  summit 
to  represent  the  external  os,  while  the  fundus  may  shrink 
till  it  becomes  a  mere  knob  surmounting  the  vagina.  The 
menopause  may  occur  prematurely,  but  otherwise  naturally, 
in  women  who  have  not  borne  children,  and  in  whom  con- 
sequently it  cannot  be  ascribed  to  superinvolution  ;  and  in 
these  cases  a  similarly  marked  atrophy  may  take  place. 

Atrophy  may  follow  also  an  artificial  menopause,  pro- 
duced by  the  removal  of  the  tubes  and  ovaries,  or  by  a 
disease  destroying  their  functions,  such  as  pelvic  inflamma- 
tion, salpingitis,  and  ovaritis.  Certain  constitutional  con- 
ditions produce  the  same  result,  especially  tuberculosis  and 
chlorosis,  less  frequently  diabetes,  Bright's  disease,  chronic 
morphinism,  insanity,  and  other  central  nervous  disorders. 
Lastly,  it  occurs  in  the  form  of  superinvolution  after  de- 
livery (see  p.   163). 


CHAPTER   XVI. 

PESSARIES. 

A  PESSARY  is  an  instrument  used  to  support  the  pelvic 
organs  in  cases  of  hernia  of  the  pelvic  floor,  or  to  maintain 
in  a  normal  position  a  uterus  which  has  a  tendency  to  flex- 
ions or  displacements. 

Pessaries  must  be  regarded  as  a  palliative  method  of 
treatment,  though  at  times  a  radical  cure  may  be  effected 
by  their  means.  In  late  years  their  use  has  been  restricted 
by  the  introduction  of  operative  measures ;  but  operations 
are  in  some  cases  contraindicated  by  the  age  or  ill-health 
of  the  patient  or  by  her  unwillingness  to  submit  to  them, 
whilst  in  other  cases  they  fail  to  reheve  the  condition  for 
which  they  are  undertaken.  Pessaries  remain,  therefore, 
indispensable,  though  they  should  be  used  as  seldom  as 
possible. 

To  be  effectual,  a  pessary  must  answer  the  following 
requirements : 

1.  It  must  maintain  the  normal  position  of  the  uterus  and 
vaginal  walls,  and  relieve  symptoms. 

2.  When  it  is  in  its  place  the  patient  should  be  uncon- 
scious of  its  presence. 

3.  It  must  be  light,  smooth,  not  acted  upon  by  the 
uterine  and  vaginal  secretions,  and  not  irritating  to  the 
vaginal  walls.  The  best  materials  for  this  purpose  are  alu- 
minum, vulcanite,  block  tin,  celluloid,  and  hardened  india- 
rubber.  The  last  three  have  the  advantage  that  they  can 
be  moulded  to  any  required  form ;  in  the  case  of  celluloid 
and  india-rubber  this  is  done  by  innnersing  them  in  boiling 

147 


148 


DISEASES   OF   WOMEN. 


Fig.  41. — The  ring  pessary. 


water,  when  they  become  soft,  refraining  their  rifjidity  on 
coohng.     Tlierc  arc  three  types  of  pessary  in  general  use. 

The  Ring  Pessary  (Fig.  41). — This  should  be  made 
of  good  hard  rubber,  with  a  central  wire  spring,  so  that  it 

may  be  compressed  to  facilitate 
introduction  and  may  regain  its 
shape  when  released. 

It  is  used  for  cystocele,  rec- 
tocele,  and  uterine  prolapse— 
i.  c.  for  hernia  of  the  pelvic  floor. 
It  should  not  touch  the  bony 
parts  of  the  pelvis,  but  should 
slightly  stretch  the  lateral  vaginal 
walls.  It  depends  for  its  efficacy 
on  the  integrity  of  the  posterior 
vaginal  wall  and  the  levator  ani, 
and  is  useless  when  the  perineum  is  much  lacerated ;  for 
then  it  comes  out  as  soon  as  the  patient  strains,  as  during 
coughing,  sneezing,  and  defecation.  The  same  result  fol- 
lows if  the  ring  be  too  small,  whilst  if  too  large  it  interferes 
with  the  action  of  the  bladder  and  rectum  and  may  cause 
vaginal  ulceration. 

A  rubber  ring  should  not  be  left  ///  situ  longer  than  six 
months  without  being  seen  to ;  for  the  rubber  tends  to 
become  rough  and  corrugated,  leading  to  irritation  of  the 
vaginal  mucous  membrane  and  profuse  leucorrhcea.  In 
some  cases  this  effect  follows  in  a  shorter  time,  three  or 
four  months ;  in  others  a  pessary  of  the  best  rubber  may 
be  worn  for  a  year  without  inconvenience. 

The  Hodge  Pessary. — This  is,  in  surface  a.spect,  rec- 
tangular, with  the  upper  angles  rounded ;  in  profile  it 
resembles  an  opened-out  S  (Fig.  42).  It  is  used  for  back- 
ward displacements  of  the  uterus,  when  the  uterus  is 
movable.  It  may  be  made  of  vulcanite,  aluminum,  cellu- 
loid, or  block  tin  ;  the  two  latter  will  be  found  most  con- 
venient, as  it  is  often  necessary  to  slightly  modif)-  the  shape 


PESSARIES.  149 

to  suit  the  requirements   of  the  individual  case.     Various 


Fig.  42. — The  Hodge  pessary. 


modifications  of  the  original  Hodge  pattern  are  found  (Fig. 
43),  but  the  important  element  of  success  in  treatment  by 


Fig.  43. — A  glycerin  pessary,  Hodge  pattern. 


means  of  pessaries  is  that  the  instrument  should  fit. 


I50  DISEASES   OE   WOMEN. 

Modes  of  Action. — Like  the  rinj^,  the  Hodge  pessary 
should  not  touch  any  bony  points.  The  action  is  described 
as  that  of  a  lever,  the  middle  portion  of  the  pessary  resting 
against  the  posterior  vaginal  wall  and  forming  the  fulcrum ; 
the  intrapelvic  pressure  acts  in  a  direction  downward  and 
backward,  mainly  against  the  lower  portion  of  the  pessary, 
and  this  tends  to  tilt  the  upper  end  forward  and  upward 
against  the  posterior  surface  of  the  body  of  the  uterus. 
Another  influence  is  exerted  also :  when  the  posterior 
vaginal  fornix  is  pushed  upward,  the  cervix  is  drawn  back- 
ward, and  if  the  uterus  be  fairly  rigid,  the  fundus  is  in  this 
way  tilted  forward.  The  backward  pressure  of  a  heavy 
uterine  body  is  also  resisted,  through  the  lever  action  of  the 
Hodge  pessary,  by  the  anterior  vaginal  wall,  as  long  as  this 
is  not  much  relaxed.  It  is  in  harmony  with  this  explana- 
tion that  the  crescent-shaped  instrument  is  used,  with  the 
lower  end  pointing  forward;  but  pressure  on  the  urethra 
must  here  be  specially  guarded  against. 

The  Vaginal  Stem  Pessary. — This  consists  of  a  cup 
or  ring  mounted  on  a  stem,  the  lower  end  of  which  projects 
from  the  vulva,  and  has  attached  to  it  perineal  bands  which 
pass  forward  and  backward  to  be  fastened  to  the  waistband 
(Fig.  44).  Such  an  instrument  is  sometimes  used  for  pro- 
lapse of  the  uterus  or  vaginal  walls  when  the  perineum  is 
so  deficient  that  a  ring  cannot  be  retained  and  the  age  or 
other  conditions  of  the  patient  do  not  allow  of  repair  of 
the  perineum.  Zwanckc's  pessary  is  on  the  same  principle, 
but  has  the  disadvantage  of  being  difficult  to  keep  clean. 

Contra-indications  to  the  Use  of  Pessaries. — No 
pessary  should  be  used  when  there  is  any  inflammatoiy 
condition  of  the  genital  organs, — pain  and  irritation  would 
be  the  result.  In  the  unmarried  pessaries  are  undesirable 
excej)t  when  .symptoms  are  severe  and  there  is  a  strong 
probability  of  cure  by  their  means.  When  the  uterus  is 
fi.xed,  pessaries  are  harmful  as  well  as  useless;  it  is  vain  to 
hope  that  the}'  will   overcome  adhesions.     So,  also,  when 


PESSARIES. 


151 


the  uterus  is  markedly  retroflexed  as  well  as  retroverted  it 
is  useless  to  put  in  a  Hodge  pessary  unless  the  flexion  be 
first  corrected ;  for  all  that  would  result  would  be  an  ante- 
version    with    retroflexion.     Whatever  the  position  of  the 


Fig.  44. — Vaginal  stem  pessary. 

uterus,  a  pessary  should  not  be  introduced  unless  the  mal- 
position gives  rise  to  symptoms. 

Retained  Pessary. — The  first  effect  of  a  pessary  long 
retained  is  vaginitis ;  if  the  vagina  has  not  been  kept  clean 
by  douching,  the  discharges  become  purulent ;  the  pessary 
hinders  their  exit,  and  comes  to  lie  ultimately  in  what  is 
practically  an  abscess-cavity.  The  bad  effects  are  aggra- 
vated by  the  contraction  of  the  vaginal  orifice  which  occurs 
at  the  menopause.  If  the  pessary  be  a  ring  or  a  Hodge, 
the  vaginal  wall  in  contact  with  it  becomes  ulcerated,  so 
that  there  results  a  groove  lined  with  granulations.  These 
tend  to  grow  up  around  the  pessary,  and  may  at  length 
grow  over  and  fuse,  forming  a  bridge  of  tissue  holding  the 
pessary  firmly  imbedded  in  the  vaginal  wall.  In  the  case 
of  a  flattened  pessary  with  perforations  the  granulations 
may  in  like  manner  sprout  and  project  through  the  perfora- 


152  DISEASES   OE   WOMEN. 

tions,  formin<j  bands  between  the  anterior  and  posterior 
vaginal  walls.  In  this  way  it  may  no  longer  be  possible  to 
remove  the  pessary  without  considerable  violence,  whilst 
this  result  is  contributed  to  also  by  the  narrowing  of  the 
vaginal  outlet.  The  pus  becomes  offensive ;  and,  if  the 
cause  of  irritation  be  not  removed,  constitutional  symptoms 
indicating  septic  absorption  may  arise. 

The  length  of  time  required  for  a  pessary  to  set  up  such 
ulceration  varies  with  the  shape  of  the  pessary  and  with 
the  frequency  or  otherwise  of  douching ;  in  the  absence  of 
douching  a  few  months  may  suffice  for  the  production  of  a 
considerable  groove,  especially  in  the  case  of  a  tightly- 
fitting  pessary  with  a  narrow  edge. 


CHAPTER   XVII. 
DISEASES  OF  THE  UTERUS  (Continued). 

INVERSION  OF  THE  UTERUS. 

A  UTERUS  is  inverted  when  it  is  turned  inside  out ;  this  is 
true  in  two  senses,  for,  as  the  organ  inverts,  its  fundus 
passes  into  the  vagina  and  is  protruded  beyond  the  vulva. 

Inversion  of  the  uterus  is  only  possible  when  its  cavity 
is  dilated ;  that  is,  during  pregnancy  or  when  a  polypus  is 
present.  In  by  far  the  greater  proportion  of  cases  the  con- 
dition is  a  complication  of  delivery  at  term,  and  is  nearly 
always  due  to  an  unskilled  individual  dragging  upon  the 
cord  of  a  still  adherent  placenta.  Although  this  variety 
of  inversion  belongs  to  the  province  of  obstetrics,  it  is 
necessary  to  briefly  review  its  leading  features. 

The  inversion  may  be  partial,  the  fundus  not  extending 
beyond  the  mouth  of  the  uterus ;  it  may  extend  through 
the  OS  uteri  into  the  vagina ;  or  the  inversion  may  be  so 
complete  that  the  uterus  from  mouth  to  fundus  is  turned 
inside  out  (Figs.  45,  46).  In  a  complete  case  of  acute  inver- 
sion, as  it  is  called  when  it  follows  immediately  on  delivery, 
the  outer  surface  is  formed  by  the  mucous  membrane  of 
the  uterus,  and  is  ragged,  vascular,  and  bleeding,  and  the 
inner  or  uterine  ostia  of  the  Fallopian  tubes  are  visible. 
The  interior  of  this  large  sac  is  lined  with  peritoneum  and 
contains  the  round  ligaments  of  the  uterus  with  the  Fallo- 
pian tubes  ;  the  ovaries,  as  a  rule,  remain  on  the  edges  of 
the  sac.  In  some  instances  small  intestine  and  omentum 
drop  into  the  cavity.     The  manner  in  which  the  tubes  and 

153 


154 


DISEASES   OF   WOMEN. 


ligaments  are  drawn  into  the  sac  is  illustrated  in  the  speci- 
men of  partial  inversion  represented  in  Fig.  47, 


Fig.  45. — Inversion  of  the  uterus  and  vagina.     The  dark  spot  on  each  side  indicates  the 
orifices  of  the  Fallopian  tubes  (Museum  Middlesex  Hospital). 

It  is  common  knowledge  that  when  a  bod)^  occupies  the 
uterine  cavity  it  stimulates  the  muscular  walls  to  expulsive 
efforts.     When  the  fundus  is  iinerted    it    is   a    solid  body 


DISEASES   OF   THE    UTERUS. 


155 


which  can  be  grasped  and  driven  onward  by  the  muscular 
efforts  of  the  walls  of  the  uterus,  which  may  continue  until 
the  uterus  turns  itself  completely  inside  out. 

This  mechanism  explains  the  method  by  which  a  sub- 
mucous   myoma    leads   to    inversion    of  the    uterus.     The 


Rov7td  ligament 
Tub, 


Ovary 


Fig.  46. — The  inverted  uterus  represented  in  preceding  figure,  opened  from  behind. 


presence  of  the  tumor  distends  the  cavity  of  the  uterus  and 
the  polypus  is  pushed  into  the  cervical  canal  by  the  muscu- 
lar efforts  of  the  uterus ;  this  traction  under  favorable 
mechanical  conditions  produces  inversion  of  the  fundus,  and 
finally  the  polypus  with  the  inverted  fundus  makes  its  ap- 
pearance in  the  vagina  or  even  protrudes  beyond  the  vulva. 


156 


DISEASES   OF   WOMEN. 


When    the    iiu'crsion   takes    place   gradually   it    is    ternied 
chronic. 

Acute  inversion  of  the  uterus  is  always  a  grave  accident; 
many  patients  die  in  a  {c\\  hours  from  shock  or  loss  of 
blood.  In  years  gone  by  the  inverted  mass  has  been  cut 
away  by  jjractitioners  in  ignorance  of  the  nature  of  the 
accident.    When  the  patient  escapes  the  immediate  dangers, 


Fig.  47. — Parti.Tl  inversion  of  a  uterus  due  to  a  polypus. 


ulceration,  sloughing,  bleeding,  and  exhaustion  destroy  her 
in  a  few  weeks  or  months. 

Chronic  inversion  of  the  uterus  has  a  different  history. 
The  patient  suffers  from  menorrhagia  or  metrorrhagia,  leu- 
corrhoea,  and  vesical  troubles,  which  lead  to  an  examination, 
and  the  tumor-like  mass  is  detected  in  the  vagina.  In 
many  cases  its  nature  is  recognized,  but  this  is  not  always  a 
simple  matter. 

Care  must  be  exercised — 


DISEASES   OF   THE    U'EERUS.  157 

1.  To  distinguish  dctzuccn  an  inverted  uterine  fundus  and 
a  uterine  polypus. 

2.  To  recog)nze  a  case  in  which  a  polypus  is  responsible 
for  the  inversion  of  the  litems. 

A  submucous  myoma  protrudini^  throui^h  the  os  uteri 
often  strikingly  resembles  a  partially  inverted  fundus. 

In  cases  of  acute  inversion  there  should  be  no  difficulty 
in  diagnosis,  but  when  the  inversion  is  of  long  standing  the 
exposed  surface  becomes  grayish-white  like  skin. 

In  partial  inversion  great  caution  in  diagnosis  is  neces- 
sary, but  with  the  help  of  the  sound  the  difficulty  is  easily 
surmounted.  When  the  sound  is  introduced  through  the 
mouth  of  the  uterus  between  the  inverted  fundus  and  the 
uterine  wall,  it  is  arrested  at  less  than  its  normal  length ;  in 
the  case  of  a  polypus  it  will  pass  to  the  full  length,  or  more 
often  to  a  greater  distance. 

In  some  cases,  especially  when  the  patient  has  a  thin 
belly-wall,  a  cup-like  depression  can  be  felt  to  replace  the 
natural  convexity  of  the  uterine  fundus.  Sometimes  this 
depression  can  be  detected  by  a  finger  introduced  through 
the  rectum.  In  doubtful  cases  an  examination  under  ether 
is  desirable,  and  if  necessary  the  urethra  can  be  dilated  and 
the  condition  of  the  uterus  determined  by  a  finger  intro- 
duced into  the  bladder. 

Treatment. — In  recent  cases  reduction  of  the  inversion 
may  often  be  effected  by  taxis.  The  patient  is  placed  under 
an  anaesthetic  and  steady  pressure  made  by  the  fingers  on 
the  walls  of  the  uterus,  near  the  cervix.  The  principle  on 
which  taxis  is  applied  for  this  condition  is  the  same  as  that 
in  reducing  a  hernia,  namely,  the  part  last  inverted  should 
be  returned  first. 

When  inversion  is  chronic  there  appears  to  be  more  risk 
and  difficulty  in  inmicdiate  reduction,  and  it  is  customary  to 
use  an  instrument  called  a  repositor  (Fig.  48).  This  instru- 
ment consists  of  a  perforated  cup-shaped  disk  fitted  on  a 
stem  which  may  be  straight  or  furnished  with  a  perineal  and 


158 


DISEASES   OE   WOMEN. 


a  pelvic  curve.  The  lower  end  of  the  repositor  permits  of 
the  attaciimcnt  of  clastic  bands  connected  to  a  waist-belt 
supported  by  braces  which  pass  over  the  shoulder.  When 
in  use  the  waist-belt  is  fitted  to  the  patient  and  secured  by 
the  braces.  The  cup  of  the  repositor  is  adjusted  to  the 
fundus  of  the  inverted  uterus,  and  the  elastic  bands  fixed  to 
the  repositor  and  waist-belt  maintain  a  continuous  pressure. 


Fig.  48. — A  uterine  repositor. 

The  patient  is  kept  in  bed,  and,  if  the  proceeding  causes 
j:)ain,  morphia  injections  may  be  given.  At  intervals  of  a 
few  hours  the  amount  of  progress  is  observed  and  the 
bands  are  readjusted.  As  soon  as  the  fundus  is  reduced 
to  the  level  of  the  internal  os  it  is  desirable  to  change  the 
cup  of  the  repositor  for  a  smaller  one,  for  when  reduction 
is  complete  a  large  cup  is  imprisoned  in  the  uterine  cavity 


DISEASES   OF   THE    UTERUS.  1 59 

and  is  sometimes  so  firmly  held  as  to  cause  difficulty  and 
anxiety  in  its  extraction.  By  means  of  the  repositor  an  in- 
verted uterus  may  be  reduced  in  twenty-four  or  forty-eight 
hours,  even  when  the  inversion  has  existed  for  some  years. 
When  inversion  is  due  to  a  polypus  the  latter  is  excised 
before  reduction  is  attempted. 


CHAPTER    XVIII. 
DISEASES  OP^  THE  UTERUS  (Continued). 


INJURIES    OF  THE    UTERUS;    DISEASES  RE- 
SULTING FROM  GESTATION. 

I/aceration  of  the  Cervix. — Causes. — Laceration  is 
sometimes  produced  by  operations  on  the  cer\'ix,  but  in  the 
vast  majority  of  cases  it  occurs  in  childbirth.  The  imme- 
diate causes  are  precipitate  labor,  a  large  or  well-ossified 
fcetal  head,  and  the  application  of  forceps  before  dilatation 
of  the  cervix  is  complete.  A  natural  labor  may  result  in 
laceration  when  the  distensibility  and  elasticity  of  the  cer\ix 
are  impaired  by  disease,  such  as  carcinoma  and  chronic 
inflammation. 

Results  of  Laceration. — When  a  cervix  is  torn  (as  during 
labor)  the  raw  edges  become  healed  over  by  granulation 

and  cicatrization,  but  as  a  rule 
without  uniting.  The  resulting 
fissure  does  not  necessarily  give 
rise  to  symptoms,  even  if  deep 
or  bilateral.  For  the  cervical 
mucous  membrane  may  grad- 
ually acquire  the  characters  of 
the  vaginal  epithelium ;  the  ex- 
ternal OS  retreats,  as  it  were, 
toward  the  internal,  while  the 
anterior  and  posterior  lips  of 
the  cervix  become  in  reality 
lips  or  lappets,  which  can  be 
readily  separated  to  a  greater  or  less  extent  (Fig.  49).     A 

160 


Fig.   49 • 


-I'ilater.il    l.icer.ition   of  the 
cervix  (A.  E.  G.)- 


DISEASES   OF   THE    UTERUS.  l6l 

cervix  in  this  condition  is  not  uncommonly  discovered 
when  a  vaginal  examination  is  made  on  account  of  other 
symptoms. 

But  the  lesion  may  take  a  less  favorable  course.  The 
exposed  cervical  mucous  membrane  may  become  unhealthy, 
either  alone  or  as  part  of  a  general  endometritis ;  it  then 
becomes  congested,  and,  in  consequence,  the  lips  become 
separated.  The  tendency  to  separation  is  exaggerated  if 
there  be  a  marked  coincident  flexion  of  the  uterus.  The 
everted  mucous  membrane  is  then  bathed  in  the  unhealthy 
secretions  (arising  partly  from  the  uterus)  found  in  the 
vagina ;  and  it  is  but  a  short  step  from  this  condition  to 
that  of  erosion,  with  the  formation  of  the  cysts  known  as 
Nabothian  follicles.  The  congestion  and  oedema  of  the  cer- 
vix commonly  spread  to  the  body  of  the  uterus,  which 
becomes  heavy  and  enlarged,  resembling  the  condition 
found  in  subinvolution.  With  the  chronic  endometritis  and 
metritis  so  produced  is  frequently  associated  prolapse  of  the 
ovaries  into  the  recto-vaginal  pouch ;  especially  when  there 
is  also  retroflexion.  The  ovaries  share  in  the  congestion 
and  become   unduly  sensitive. 

Signs  and  Symptoms. — A  lacerated  cervix  does  not,  as 
such,  give  rise  to  symptoms,  except,  occasionally,  bleeding 
in  recent  cases.  Such  symptoms  as  are  present  depend  on 
the  accompanying  endometritis,  and  include  leucorrhoea, 
sacral  aching,  a  feeling  of  weight  and  "  bearing  down  "  in 
the  pelvis,  and  dyspareunia. 

From  time  to  time  lacerations  have  been  held  responsible 
for  many  reflex  neuroses  ;  we  believe  this  to  be  entirely 
erroneous  ;  for  although  such  neuroses  have  disappeared 
after  repair  of  the  cervix,  the  improvement  must  be  attrib- 
uted to  the  simultaneous  curing  of  the  inflammatory  con- 
dition. 

A  laceration  is  readily  detected  by  digital  examination 
and  may  be  seen  by  the  use  of  the  speculum.  Lacerations 
vary  in  nature  and  extent.  There  may  be  a  split  on  one 
11 


l62 


DISEASES   OE  WO.VEN. 


side  only,  the  cleft  exteiuiinj^f  only  a  short  distance  from  the 
external  os,  or  reaching  up  to  the  junction  of  the  cervix 
and  vaj^ina.  It  is  more  frccjuent  on  the  left  side,  running  a 
little  forward,  and  sometimes  bifurcated  externally ;  and 
this  is  attributed  to  the  greater  frequency  of  the  left  occip- 
ito-antcrior  position  of  the  child  during  deliver^' (Fig.  50,  a\ 
An  occipito-posterior  position  will  cause  a  laceration  of  the 
{josterior  lip  (Fig.  50,  B).  In  other  cases  this  split  is  bilat- 
eral, so  that  the  cervix  presents  well-marked  anterior  and 


C  D 

Fig.  so. — Four  diagrams  to  indicate  the  positions  of  cervical  lacerations. 


posterior  flaps  (Fig.  50,  D) ;  or  several  fissures  may  be 
found,  radiating  from  the  external  os  (Fig.  50,  c).  A  Fer- 
gusson's  speculum  somewhat  masks  the  extent  of  lacera- 
tion by  holding  the  lips  in  contact ;  some  form  of  bivalve 
speculum  gives,  therefore,  a  better  view.  The  presence  of 
a  complicating  endometritis  will  be  determined  at  the  same 
time. 

A  bilateral  laceration  with  considerable  eversion  of  the 
mucous  membrane  may  resemble  adenomatous  disease  with 
but  slight  laceration,  because  the  two  lips  cannot  be  brought 
together;  on  relieving  the  congestion  by  scarification  the 
true  condition  will  be  rccocrnized. 


DISEASES   OF   THE    UTERUS.  163 

Treatment. — When  no  inflammatory  conditions  arc  present 
no  treatment  is  required,  except  as  a  prophylactic  measure. 
Inasmuch  as  laceration  predisposes  to  endometritis,  it  may 
often  be  considered  advisable  to  repair  the  rent  with  a  view 
to  diminishing  the  risk. 

When  the  laceration  is  followed  by  the  more  serious 
results  above  described,  the  operation  of  trachelorrhaphy 
or  repair  of  the  cervix  is  indicated. 

Perforation  of  tlie  Uterus. — This  may  occur  as  the 
result  of  the  incautious  use  of  the  sound  or  of  metallic  di- 
lators ;  even  when  carefully  used  a  sound  may  pass  through 
the  uterine  wall  in  some  diseased  conditions  where  the  wall 
is  soft,  friable,  or  thin,  as  in  sarcoma,  carcinoma,  and  cystic 
degeneration  of  the  chorion  (hydatid  mole).  When  this 
accident  occurs  the  sound  passes  considerably  beyond  the 
normal  distance,  and  its  point  may  sometimes  be  felt  under 
the  abdominal  wall.  Bleeding  may  result,  but  it  is  seldom 
considerable.  With  a  clean  instrument  and  a  fairly  healthy 
uterus  no  untoward  symptoms  may  follow,  but  in  the 
opposite  conditions  septic  peritonitis  may  be  set  up,  with 
serious  or  fatal  results. 

DISEASES  RESULTING  FROM  GESTATION. 

Superinvolution. — This  signifies  premature  atrophy  of 
the  uterus  following  delivery.  It  is  brought  about  by  de- 
bilitating causes,  such  as  multiple  and  frequent  pregnancies, 
post-partum  hemorrhage,  and  prolonged  lactation.  Some- 
times there  is  no  apparent  cause. 

The  condition  may  be  permanent,  leading  to  a  premature 
menopause;  or  temporary,  the  uterus  regaining  its  proper 
size  as  the  patient  recovers  strength.  The  only  symptoms 
are  diminution  or  cessation  of  menstruation,  and  sterility. 
On  physical  examination  the  uterus  is  found  to  be  small. 
The  diminution  affects  the  substance  of  the  uterine  walls 
rather  than  the  length  of  its  cavity ;  consequently  the 
bimanual  examination  irives  more  reliable  information  than 


164  DISEASES   OE   WOMEN. 

the  passafTc  of  the  sound ;  and  for  the  same  reason  extra 
care  is  required  in  the  use  of  the  sound,  as  the  thin  and 
often  softened  walls  are  easily  perforated. 

Treatment. — We  must  rely  principally  on  hygienic  meas- 
ures and  the  administration  of  tonics  ;  the  prognosis,  how- 
e\'cr,  is  not  \-cr\'  favorable. 

Subinvolution. — By  this  is  meant  a  condition  in  which 
the  return  of  the  uterus  to  its  proper  size  after  delivery  is 
arrested. 

Causes. — Subinvolution  may  be  due  to — 

(i)  Debility  brought  about  by  malnutrition  ;  by  a  severe 
and  lengthy  labor ;  by  post-partum  hemorrhage ;  or  by 
too  early  resumption  of  active  duties  after  delivery. 

(2)  Chronic  endometritis  preceding  labor.  Post-partum 
hemorrhage  is  very  likely  to  occur  in  such  a  case,  and  it 
must  then  be  regarded,  not  as  the  cause  of  subinvolution, 
but  as  the  result  of  conditions  leading  also  to  subinvolu- 
tion. Indeed,  it  is  possible  that  the  relation  of  hemor- 
rhage and  subinvolution  should  always  be  regarded  in  this 
way. 

(3)  Puerperal  endometritis. 

Pathology. — Subinvolution  presents  two  varieties,  depend- 
ing on  its  origin,  whether  inflammatory  or  trophic.  In  the 
trophic  variety  the  muscle-fibres  are  large  and  pale,  and 
the  intermuscular  tissue  and  mucosa  are  cedematous.  The 
vessels  and  l)'mphatics  are  dilated  from  the  want  of  proper 
muscular  contraction.  For  the  pathology  of  the  inflamma- 
tory variety  see  Chapter  XIX. 

Signs  and  Symptoms. — Besides  general  weakness,  the 
sj'mptoms  are — abundance  and  long  duration  of  the  lochia; 
irregular  losses  after  the  lochia  proper  ha\e  ceased  ;  pro- 
fuse leucorrhoea ;  a  feeling  of  weight  in  the  pelvis ;  and 
backache.  On  examination  the  vagina  is  bathed  in  dis- 
charge of  a  serous  or  sero-purulent  character,  sometimes 
tinged  with  blood.  The  uterus  is  large,  heavy,  and  flabby, 
and  not  uncommonly  retrovertcd. 


DISEASES    OE   THE    UTERUS. 


165 


The  condition  must  be  diagnosed  from  retention  of  prod- 
ucts of  conception ;  in  the  latter  case  bleeding  is  more 
marked,  but  otherwise  the  signs  and  symptoms  are  so 
similar  that  exploration  of  the  interior  of  the  uterus  may 
be  required  to  establish  the  diagnosis. 

Trcatinoit. — The  general  treatment  should  be  tonic  with 
rest  in  bed.  Hot  intra-uterine  and  vaginal  douches  should 
be  given,  as  these  induce  uterine  contractions  which  play 
an  important  part  in  the  process  of  involution.  In  more 
chronic  conditions  hydrotherapeutics  and  change  of  air 
are  indicated,  and  applications  of  the  galvanic  current,  the 
negativ^e  pole  being  placed  inside  the  uterus.  In  the  way 
of  medicines  ergot  may  be  given,  in  combination  with  iron. 

Retention  of  Products  of  Conception. — A  portion 
of  placenta  or  of  membranes  may  remain  attached  to  the 


Fig.  51. — Retained  fragment  of  placenta  (Museum  R.  C.  Surgeons). 

uterine  wall,  both  after  full-time  delivery  and  after  abortion. 
It  is  most  frequent  in  the  latter  case.     The  principal  symp- 


i66 


DISEASES   OF  WOMEN. 


Fig.  53. — Microscopic  appearance  tf  v'  "-'-"t^!  li^vaj  1   ng  retained  in  the  uterus  (A.  E.  G). 


DISEASES   OF   THE    UTERUS.  167 

torn  is  irrc<Tular  hemorrhaf^e,  continued  in  some  instances 
for  many  months.  The  other  symptoms  and  the  physical 
signs  closely  resemble  those  just  described  as  resulting 
from  subinvolution. 

The  diagnosis  generally  rests  between  retention  of  pla- 
cental fragments,  polypus,  and  sarcoma,  but,  clinically,  a 
placental  remnant  forms  one  variety  of  polypus  (Fig.  51). 
In  any  case  the  diagnosis  cannot  be  made  with  certainty 
without  exploration  of  the  interior  of  the  uterus.  The 
microscopic  characters  of  recent  placental  tissue  are  shown 
in  Fig.  52,  and  those  of  such  tissue  when  retained  for  some 
time  in  the  uterus,  in  Fig.  53. 

Treatment. — When  symptoms  are  not  urgent,  palliative 
measures  may  be  adopted,  such  as  the  administration  of 
ergot  and  iron,  and  vaginal  douches.  But  if  there  be 
reason  to  suppose,  at  the  outset,  that  retained  products  are 
present,  there  is  no  object  in  delay,  and  the  uterine  cavity 
should  be  explored.  Shortly  after  a  Labor  or  miscarriage 
the  cervix  may  be  sufficiently  patulous  to  allow  of  this 
being  done  without  dilatation.  In  other  cases  dilatation 
must  precede  exploration,  which  should  be  done  by  means 
of  the  finger  in  the  uterus.  If  placental  fragments  are 
found,  the  curette  should  be  used,  removing  all  rough  and 
protruding  parts  of  the  surface  until  the  interior  is  quite 
smooth. 


CHAPTER   XIX. 
DISEASES  OF  THE  UTERUS  (Continued). 

DISEASES  OF  THE   ENDOMETRIUM. 

The  mucous  membrane  lining  the  ca\  it\'  and  the  cervical 
canal  of  the  uterus  is  termed  the  endometrium.  It 
differs  from  mucous  membranes  in  general  in  having  no 
submucous   layer  (Fig.    54) ;  this   is  due  to   the   fact  that 


Fig.  54. — Horizontal  section  of  the  body  of  the  uterus  of  an  adult ;  ^  natural  size  (Henle). 

nearly  the  whole  of  the  muscular  tissue  of  the  uterus  is 
morphologically  muscularis  mucosae  (John  Williams).  Com- 
parative anatomy  supports  this  view.  The  endometrium  is 
peculiar  in  undergoing  rhythmic  changes  during  sexual  life 
coincident  with  menstruation  ;  when  the  uterus  is  occupied 
by  an  oosperm  (fertilized  ovum)  the  endometrium  of 
the  uterine  cavity  is  changed  into  a  thick  membrane  known 
as  a  decidua,  which  is  incorporated  with  and  shed  coinci- 
dently  with  the  placenta.  Menstrual  and  decidual  changes 
are  entirely  confined  to  the  endometrium  lining  the  uterine 
cavity.  The  mucous  membrane  lining  the  cervical  canal  is 
called  the  cervical  endometrium.  The  endometrium  of 
the  uterine  cavity  has  a  smooth  surface,  it  is  soft,  spongy, 
red,  and  covered  with  ciliated  columnar  epithelium.  The 
168 


DISEASES   OE   THE    UTERUS.  1 69 

glands  vvliich  beset  it  are  simple  tubes  lined  with  a  single 
layer  of  columnar  cells  continuous  with  those  on  the  sur- 
face ;  the  cells  near  the  orifices  of  the  glands  are  ciliated. 
The  glands  dip  obliquely  into  the  stroma  of  the  mucous 
membrane  and  sometimes  bifurcate  at  the  extremity.  The 
cervical  endometrium  is  firm  and  forms  rug.Te,  giving  rise  to 
an  appearance  known  as  the  arbor  vita.  The  orifices  of 
the  racemose  glands  open  on  the  surface  in  the  pits  between 
the  rugae.  The  epithelium  in  the  upper  half  of  the  cervi- 
cal canal  is  of  the  columnar  ciliated  variety,  in  the  lower 
half  it  is  stratified.  In  addition  to  the  glands,  the  mucous 
membrane  of  the  lower  part  of  the  canal  contains  numerous 
vesicles  visible  to  the  naked  eye  and  known  as  the  ovules 
of  Nabotli. 

The  endometrium  is  liable  to  the  following  diseases  :  i. 
Inflammation;  2.  Adenomatous  Disease;  3.  Tuberculosis; 
4.  Sarcoma;    5.  Carcinoma. 

Acute  Endometritis. — The  chief  causes  are  sepsis  (in- 
fection with  micro-organisms)  following  labor  or  abortion  ; 
instrumental  interference  with  the  uterus ;  extension  of 
vaginitis  or  gonorrhcea ;  or  gangrene  of  a  uterine  myoma. 

When  inflamed,  the  endometrium  presents  the  usual  cha- 
racters of  an  inflamed  mucous  membrane  ;  it  is  swollen, 
and  the  surface  is  covered  with  a  purulent  exudation.  On 
microscopic  examination  its  tissues  are  found  infiltrated  with 
leucocytes,  and  if  submitted  to  bacteriological  examination 
the  infiltrated  tissues  and  discharges  will  occasionally  fur- 
nish the  micro-organism  which  initiated  the  disturbance. 
The  great  difficulty  which  besets  the  study  of  morbid  states 
of  the  endometrium  is  the  fact  that  in  order  to  examine  it 
the  cervical  canal  must  be  dilated ;  even  then  the  informa- 
tion can  only  be  acquired  by  the  finger,  or  more  directly 
from  the  study  of  fragments  removed  from  it  by  means  of 
the  curette. 

In  recent  years  a  good  deal  of  useful  work  has  been 
accomplished,  and  we  know  that  acute  endometritis  follow- 


170  DISEASES   OF   WOMEN. 

xwg  on  labor  and  abortion — "  puerperal  endometritis  "  as  it  is 
called — is  caused  by  the  introduction  of  pathogenic  micro- 
organisms, such  as  the  streptococcus  and  staphylococcus, 
due  to  lack  of  scrupulous  aseptic  precautions  on  the  part  of 
doctor,  midwife,  or  nurse.  These  minute  bodies  flourish  in 
the  discharges,  and  lead  to  decomposition  of  blood-clot  or 
fragments  of  placenta  which  may  be  retained  in  the  uterine 
cavity.  The  ultimate  course  and  consequence  of  endome- 
tritis occurring  during  the  puerperium,  or  as  a  sequence  of 
operations  on  the  uterus,  or  due  to  gangrene  of  a  myoma 
or  extension  of  gonorrhoea,  are  much  the  same. 

In  many  cases,  especially  when  the  infection  is  of  a  mild 
type,  the  inflammation  subsides,  and,  like  those  conditions 
called  catarrh,  leaves  no  trace.  In  others  the  inflammatory 
changes  may  extend  beyond  the  mucous  membrane  into 
the  muscular  wall  of  the  uterus,  and  even  involve  its  serous 
covering.  When  endometritis  involves  the  uterus  in  this 
way  it  is  sometimes  called  metritis  (an  unnecessary  refine- 
ment). When  the  infection  is  very  virulent  it  will  lead  to 
gangrene  and  sloughing  of  the  endometrium. 

The  most  serious  consequence  of  the  disease  is  due  to  its 
extension  to  the  mucous  membrane  of  the  Fallopian  tubes ; 
then  the  infectious  material  finds  its  way  directly  into  the 
pelvic  section  of  the  coelom  (peritoneal  cavity)  and  in  many 
instances  with  a  fatal  result.  (This  disaster  is  discussed  in 
the  chapter  devoted  to  Salpingitis.) 

Signs. — Constitutional  disturbance  is  the  rule,  except  in 
gonorrheal  endometritis  ;  apart  from  the  febrile  disturbance 
the  patient  complains  of  pelvic  pain  and  profuse,  offensive, 
purulent,  and  sometimes  blood-stained  discharges.  Rigors 
are  not  uncommon,  and  the  temperature  ranges  from  99° 
or  100°  to  105°  F. 

On  examination  the  vagina  is  hot,  and  before  the  stage  of 
abundant  discharge  may  be  dry.  The  uterus  feels  heavy 
and  bulky,  and  is  tender  to  manipulation.  Later  it  becomes 
fixed  if  pelvic  cellulitis  supervenes.     The  cervix  is  at  first 


DISEASES   OE   THE    UTERUS.  I7I 

soft,  but  later  it  is  hard  and  firm.  Viewed  through  the 
speculum,  the  cervix  appears  red  and  thickened,  and  mu- 
cus, either  viscid,  muco-purulent,  or  sanious,  is  seen  to 
exude  from  the  external  os. 

Diagnosis. — The  history  and  the  febrile  condition  will 
point  to  the  diagnosis,  and  lead  to  vaginal  examination, 
when  the  above  conditions  will  be  found. 

Course  and  Prognosis. — Acute  endometritis  of  puerperal 
origin  is  the  only  one  which  is  at  all  frequently  fatal,  and 
then  the  fatal  result  depends  more  on  general  than  on  local 
conditions.  In  all  other  cases  the  tendency  is  to  recovery 
after  a  more  or  less  protracted  convalescence.  The  most 
serious  complications  are  pelvic  peritonitis  and  cellulitis, 
pyosalpinx,  and  sterility.  Uncomplicated  endometritis  re- 
sults usually  in  no  more  serious  condition  than  a  chronic 
hyperplasia,  \vhich  may  induce  dysmenorrhoea  and  some- 
times sterility. 

Treatment. — The  patient  must  be  kept  in  bed  and  the 
usual  treatment  of  febrile  conditions  adopted.  For  the 
treatment  of  puerperal  septicaemia  the  student  is  referred 
to  text-books  of  obstetrics. 

As  regards  local  treatment,  much  may  be  done.  Thus 
at  the  outset  intra-uterine  irrigation  should  be  resorted  to, 
using  for  this  purpose  solutions  of  perchloride  of  mercury 
(i  :  5000)  carbolic  acid  (i  140) ;  nitrate  of  silver  (i  :  500),  or 
chloride  of  zinc  (i  per  cent.).  The  irrigation  may  be  fol- 
lowed by  the  introduction  of  iodoform  pencils  into  the 
uterine  cavity,  or  by  swabbing  out  the  uterus  with  a 
stronger  caustic  (iodized  phenol,  liniment  of  iodine,  or 
chloride  of  zinc  10  per  cent.)  applied  on  an  intra-uterine 
probe  swathed  with  cotton-wool. 

Some  have  strongly  recommended  curetting  for  gonor- 
rhoeal  endometritis  ;  there  is,  however,  the  risk  of  opening 
up  fresh  surfaces  to  infection ;  and  the  same  objection  ap- 
plies to  dilatation  of  the  cervical  canal  for  intra-uterine 
medication.     The  risk  may  be  diminished  by  following  up 


172  DISEASES   OF   WOMEN. 

the  curetting  by  swabbing  out  the  uterine  cavity  and  the 
introduction  of  iodoform  pencils. 

As  the  N'agina  is  often  also  affected,  especially  in  gonor- 
rhceal  cases,  it  must  be  treated  at  the  same  time,  as  pre- 
viously described. 

Much  benefit  is  derived,  in  the  earlier  stages,  from  scari- 
fication of  the  cervix  and  the  abstraction  of  blood ;  this 
answers  better  than  leeches,  which  were  formerly  used  for 
this  purpose.  It  may  require  to  be  repeated  several  times, 
at  intervals  of  a  few  days. 

The  after-treatment  consists  in  the  employment  of  hot 
vaginal  douches  of  weak  antiseptics  twice  daily.  After 
each  douche  an  iodoform  tampon  may  be  placed  in  the 
vagina,  or  a  glycerin  tampon  dusted  over  with  iodoform. 

In  addition  to  or  in  place  of  the  vaginal  douches  hot  sitz- 
baths  may  be  given.  Pain  is  greatly  relieved  by  fomenta- 
tions applied  to  the  lower  part  of  the  abdomen  and  to  the 
perineum ;  in  other  cases  morphia  suppositories  may  be 
introduced  into  the  rectum  or  opium  given  by  the  mouth. 

Chronic  Bndometritis. — Cmiscs — (i)  This  disease  may 
be  a  sequela  of  the  acute  form ;  (2)  it  may  be  due  to  gonor- 
j;hoea  or  sepsis,  without  a  preliminary  acute  stage  ;  (3)  it  may 
result  from  chronic  congestion,  due  to  catching  cold  during 
a  menstrual  period  or  caused  by  uterine  displacement ;  (4) 
it  may  result  from  abortion  or  delivery  at  term,  when  it 
takes  the  form  of  subinvolution. 

Pathology. — The  changes  found  in  the  mucosa  are  similar 
to  those  that  occur  in  acute  endometritis,  but  they  are  less 
marked.  Moreover,  several  varieties  are  described,  accord- 
ing to  the  structures  principally  affected. 

(a)  Gla7idnlar  Endometritis. — The  glands  are  enlarged 
and  dilated,  and  their  lumen  is  occupied  by  proliferating 
and  cast-off  epithelium,  mixed  with  mucus.  This  condition 
must  be  distinguished  from  adenomatous  disease  of  the 
endometrium  (page  174),  in  which  there  is  a  new  formation 
of  glandular  elements. 


DISEASES   OE   THE    UTERUS.  1 73 

(b)  Interstitial  Endometritis. — Here  the  glands  are  not 
directly  affected,  but  the  stroma  shows  at  first  increase  in 
its  cells  and  infiltration  of  leucocytes,  and  later  a  great  for- 
mation of  fibrous  tissue.  The  vessel-walls  are  thickened, 
and  small  retention-cysts  are  formed  in  the  deeper  layers  by 
pressure  on  the  gland-ducts.  Eventually  the  glands  may 
almost  disappear,  the  mucosa  consisting  chiefly  of  fibrous 
tissue. 

(c)  Hemorrhagic  Endometritis. — The  principal  alteration 
is  in  the  vessels,  which  are  dilated  and  in  places  ruptured, 
leading  to  extravasation  of  blood  in  the  superficial  layers  of 
the  stroma.  There  is  no  polypoidal  formation,  such  as  is 
found  in  the  adenomatous  condition  to  which  the  same 
name  is  sometimes  applied  (see  page   178). 

These  three  conditions  are  sometimes  found  associated 
in  the  same  specimen  ;  and  the  endometrium  of  the  cervix 
and  body  may  be  affected  separately  or  together. 

The  symptoms  and  signs  are  practically  those  of  adeno- 
matous disease,  and  similar  local  treatment  is  required. 


CHAPTER    XX. 
DISEASES  OF  THE  UTERUS  (Continued). 

DISEASES    OF    THE    ENDOMETRIUM 

(Continued). 

Adenomatous  Disease  {Erosion)  of  the  Cervical 
Kudometrium. — The  mucous  membrane  covering  the 
neck  of  the  uterus  consists  of  two  portions :  one  hnes  the 
cervical  canal — the  cervical  ciidoinctriiivi  ;  the  other  covers 
the  vaginal  portion  of  the  cervix  and  belongs  to  the  vagina. 
The  two  portions  meet  at  the  external  os.     "  The  mucous 


Fig.  55. — Adcnomntoii?;   disease  of  the 
cervix  (A.  E.  G). 


Fig.  56. — Adenom.Ttous    disease    of  the 
cervix,  with  distended  follicles  (A.  E.  G.). 


membrane  covering  the  vaginal  aspect  of  the  cerx'ix  is 
really  a  cup  of  .stratified  epithelium,  rescmbUng  a  tailor's 
thimble,  which  fits  on  the  lower  end  of  the  uterus  "  (Wil- 
liams). It  contains  a  few  simple  glandular  crypts.  The 
cervical  endometrium  in  its  lower  segment  is  beset  with 
racemose  glands  and  the  ovules  of  Naboth.  The  glands 
174 


DISEASES   OE  THE    UTERUS. 


175 


of  the  cervical  endometrium  arc  very  ajit  to  enlarge  and 
multiply,  forming-  a  soft,  velvety,  pink  mass  which  extends 
beyond  the  normal  limit,  of  the  external  os  and  invades  the 
tissue  of  the  vaginal  portion  of  the  cervix,  forming  a  soft, 
velvety  areola,  in  color  like  a  ripe  strawberry,  and  minutely 
dotted  with  spots  of  a  brighter  pink  (Figs.  55,  56).  The 
surface  is   usually  covered  with  tenacious  mucus. 

This  pink  tissue  is  composed  of  glandular  acini  lined  with 
columnar  epithelium  (Figs.   57,  58).     In  cases  of  bilateral 


Fig.  57. — Microscopic  characters  of  adenomatous  disease  of  the  uterus  (A.  E.  G.) 


laceration  of  the  cervix  the  whole  of  the  exposed  surface 
is  generally  tumid  with  this  overgrown  glandular  tissue. 
Occasionally  this  glandular  overgrowth  projects  as  a 
pedunculated  process  from  the  mouth  of  the  uterus,  and  is 
then  termed  a  mucous  polypus ;  two  or  more  may  be 
present.  They  are  dotted  with  minute  pores  indicating  the 
orifices  of  the  glands,  and  are  soft.  They  usually  spring 
from  the  endometrium  near  the  os,  which  is  generally 
patulous  when  these  pedunculated  adenomatous  bodies  are 


176 


DISEASES   OE   WOMEN. 


present.  Histologically,  they  arc  composed  of  an  axis  of 
fibrous  and  nuiscular  tissue  covered  with  mucous  mem- 
brane. As  lonf^  as  the  bodies  ren^ain  in  the  cervical  canal 
the  mucous  membrane  covering  them  possesses  a  single 
layer  of  columnar  epithelium,  but  when  the  polypus  pro- 
jects into  the  vagina  the  mucous  membrane  of  the  pro- 
truding portion  loses  its  glands,  or  they  become  mere 
crypts,  and  the  epithelium  stratifies. 

In  some'instances  the  pink  tissue  is  small  in  quantity  and 
is  dotted  with  numerous  cystic  bodies  of  the  size  of  cori- 


FlG.  58. — Microscopic  chaiacters  of  adenomatous  disease  of  the  cervix  (A.  E.  G.). 

andcr  seeds ;  these  are  enlarged  ovules  of  Naboth,  and  are 
probably  due  to  distention  of  the  acini  of  the  cervical 
glands.  When  the  adenomatous  surface  is  extensive  and 
the  follicles  are  numerous,  the  white  dots  on  a  pink  ground 
produce  a  characteristic  appearance. 

In  very  rare  cases  a  group  of  follicles  will  hang  avS  a 
grape-like  mass  in  the  vagina.  These  may  be  called  race- 
mose adenomata. 


DISEASES   OF   THE    UTERUS.  1 77 

Causes. — Nothin^^  is  known  concerning  the  cause  of  this 
affection.  It  occurs  in  virgins  and  in  mothers ;  extensive 
adenomatous  patches  are  often  associated  with  lacerations 
of  the  cervix,  and  the  disease  is  more  common  in  women 
who  have  had  children  than  in  nulliparae. 

Syiiiptoins. — Adenomatous  disease  of  the  cervix  gives 
rise  to  vaginal  discharge,  indefinite  pain,  and  general  weak- 
ness. 

The  discharge  is  commonly  known  as  "  the  whites ;" 
technically  it  is  termed  leucorrhcea.  The  normal  secretion 
is  clear  and  viscid  like  the  white  of  an  q.%^,  but  in  marked 
cases  of  adenomatous  disease  it  may  be  yellow  or  greenish. 
Pain  usually  assumes  the  form  of  backache ;  often  it  is  re- 
ferred to  the  submammary  region,  and  occasionally  to  the 
perineum.  Pruritus  is  sometimes  present.  The  continual 
discharge  weakens  the  patient  and  leads  to  many  subjec- 
tive signs,  such  as  nausea,  headache,  giddiness,  sleepless- 
ness, and  similar  disturbances,  often  attributed  to  hysteria 
and  vaguely  classed  as  neuroses. 

Diagnosis. — On  inspecting  the  vulva  traces  of  the  dis- 
charge are  usually  visible  externally.  On  examining  with 
the  finger,  the  cervix  may  feel  enlarged  and  softer  than 
usual ;  the  uterus  may  be  bulky.  On  introducing  a  specu- 
lum, tenacious  secretion  will  be  seen  covering  the  exposed 
surface  or  issuing  from  the  cervical  canal.  This  is  removed 
by  a  cotton-wool  dab,  and  the  presence,  extent,  and  cha- 
racter of  the  adenomatous  tissue  determined,  as  well  as  the 
existence  and  degree  of  any  coexisting  laceration.  The 
conditions  most  likely  to  be  confounded  with  this  disease 
are  epithelioma  and  carcinoma  of  the  cervix. 

Treatment. — When  the  disease  is  of  small  extent  it  is 
easily  dealt  with  in  the  following  manner :  The  parts  are 
well  exposed  by  means  of  a  Fergusson's  speculum,  and 
the  mucus  removed  by  means  of  cotton-wool  dabs  on 
sponge-holders  or  speculum-forceps.  Iodized  phenol  (iodine 
four  parts,  carbolic  acid  one  part)  is  then  freely  applied  to 

12 


1/8  DISEASES   OF   WOMEN. 

tlie  diseased  surface  by  means  of  cotton-wool  wound  on  a 
uterine  probe ;  it  is  useful  to  apply  some  of  the  caustic  for 
a  short  distance  up  the  cervical  canal  by  means  of  the 
probe.  If  there  be  any  conspicuous  follicles  they  should 
be  punctured.  A  tampon  is  then  introduced  and  the 
patient  directed  to  douche  the  vagina  daily,  to  keep  the 
bowels  open  by  means  of  simple  saline  purges,  and  to 
abstain  from  alcohol.  In  some  cases  one  aj^plication  of 
the  iodized  phenol  is  sufficient. 

When  the  disease  assumes  the  polypoid  form  the  pro- 
cesses are  easily  detached  with  forceps  or  a  curette. 

When  the  disease  is  more  extensive  it  may  require  several 
applications  at  intervals  of  a  week,  but  in  these  cases  better 
results  are  obtained  by  placing  the  patient  under  ether  and 
thoroughly  destroying  the  adenomatous  tissue  by  means  of 
Paquelin's  cautery,  or  scraping  it  away  with  a  curette,  tak- 
ing care  to  deal  with  the  whole  length  of  the  cervical  canal, 
and  then  applying  the  cautery,  iodized  phenol,  or  any  suit- 
able caustic  to  the  denuded  surface.  Radical  treatment  of 
this  kind  entails  rest  in  bed  for  a  week  or  ten  days. 

When  adenomatous  disease  is  associated  with  bilateral 
laceration  and  is  clearly  a  source  of  suffering,  the  perform- 
ance of  trachelorrhaphy  is  indicated. 

Adenomatous  Disease  of  the  Corporeal  Bndome- 
trium. — The  endometrium  lining  the  cavity  of  the  uterus 
is  beset  with  tubular  glands,  which,  like  the  glands  of  the 
cervical  endometrium,  may  undergo  local  enlargement  and 
form  sessile  or  pedunculated  processes  known  as  mucous 
polypi.  They  possess  a  covering  of  columnar  epithelium 
and  a  framework  of  connective  tissue  containing  glands 
identical  with  the  tubular  glands  of  the  endometrium. 

This  disease  is  sometimes  described  as  villous  or  poly- 
poid endometritis.  When  menorrhagia  and  metrorrhagia 
are  prominent  symptoms  it  is  sometimes  referred  to  as 
hemorrhagic  endometritis. 

SymptODis. — These  consist  of  a  uterine  discharge  which 


DISEASES   OF   THE    UTERUS.  1 79 

may  be  mucoid,  muco-purulcnt,  or  bloodstained.  In  many 
cases  there  is  a  distinct  history  of  menorrhagia. 

Diagnosis. — On  examination  the  uterus  is  usually  en- 
larged, and  the  introduction  of  the  sound  is  followed  by  a 
slight  loss  of  blood. 

In  many  cases  the  only  way  of  actually  determining  the 
nature  of  the  case  is  to  anaesthetize  the  patient,  dilate  the 
cervical  canal,  and  explore  the  endometrium  with  the  finger. 
Should  any  polypi  be  detected,  they  are  easily  detached 
by  means  of  the  curette. 

Treatment. — This  turns  upon  the  diagnosis,  and  is  usually 
carried  out  at  the  time  the  uterus  is  dilated ;  it  consists  in 
completely  removing  the  polypus  or  polypi,  and  then  cu- 
retting the  endometrium  and  applying  iodized  phenol. 

Tuberculosis. — This  disease  may  attack  any  part  of  the 
endometrium ;  it  occurs  more  frequently  in  the  mucous 
membrane  of  the  uterine  cavity  than  in  that  lining  the  cer- 
vical canal.  Nothing  is  known  of  its  early  stages,  for  the 
majority  of  cases  do  not  come  under  observation  until  the 
disease  has  reached  its  caseous  stage  and  has  infiltrated  the 
muscular  wall  of  the  uterus.  Occasionally  isolated  nodules 
are  found  in  the  endometrium.  The  infection  is  very  liable 
to  spread  to  the  Fallopian  tubes  and  infect  the  peritoneum 
(Chapter  XXXIII.) ;  a  very  large  proportion  of  cases  of 
general  tuberculosis  of  the  peritoneum  arise  in  this  way. 

Tuberculosis  of  the  endometrium  is  not  frequent  as  a 
primary  disease,  but  in  many  cases,  especially  in  children, 
it  is  associated  with  tubercular  lesions  in  the  lungs  and 
bones. 

It  is  by  no  means  easy  to  demonstrate  the  presence  of 
bacilli  in  the  uterine  lesions  ;  the  same  holds  true  of  the 
tubes,  but  when  tubercular  lesions  are  found  in  other  parts 
of  the  body  as  well  as  the  uterus,  and  yield  tubercle  bacilli 
to  appropriate  tests,  the  inference  that  the  uterine  lesions 
are  likewise  tubercular  is  a  fair  one. 

Tuberculosis  of  the  endometrium  is  frequent  in  children 


l8o  DISEASES   OF   WOMEN. 

and  nia}'  occur  in  the  first  )car  of  life.  This  is  a  fict  of 
some  importance  in  opposition  to  the  theory  tliat  infection 
may  be  conveyed  with  the  semen  during  coitus. 

Tuberculosis  of  tiie  uterus  is  very  rarely  made  out  during 
life;  its  presence  may  be  suspected  in  the  case  of  )'oun^ 
girls  and  young  virgins  with  a  persistent  purulent  vaginal 
discharge,  especially  if  tubercular  foci  can  be  localized  in 
their  lungs  or  bones. 

Trcattncnt. — This  disease  is  so  seldom  diagnosed  that 
radical  measures  have  rarely  been  practised  on  the  endo- 
metrium (see  Tuberculosis  of  the  Fallopian  Tubes). 


CHAPTER    XXI. 
DISEASES   OF   THE    UTERUS    (Continued). 

MYOMATA  (FIBROIDS). 

Before  describing  the  characters  of  uterine  myomata  it 
is  necessary  to  consider  a  few  points  in  relation  to  the  dis- 
tribution of  the  muscular  fibres  of  the  uterus. 

The  uterus  is  a  muscular  organ,  and  its  fundus  with  the 
chief  portion  of  its  body  is  closely  invested  with  peritoneum 
directly  continuous  with  the  lateral  folds  known  as  the  broad 
ligaments  (or  the  mesometria).  The  cavity  of  the  uterus 
is  lined  with  mucous  membrane  (the  endometrium)  rich  in 
glands  and  tracts  of  unstriped  muscle-tissue.  (The  student 
should  refer  to  the  morphological  view  of  the  nature  of  the 
uterine  wall  on  p.  i68.) 

In  regard  to  the  serous  investment  of  the  uterus,  it  is 
important  to  remember  that  in  many  situations  the  sub- 
serous tissue  is  practically  a  bed  of  fat,  but  where  it  comes 
into  relation  with  the  uterus  it  consists  of  a  layer  of  un- 
striped muscular  fibre  directly  continuous  with  the  uterine 
tissue  and  with  the  muscular  layer  of  the  mesometrium. 
In  young  adults  this  stratum  may  be  separated  from  the 
uterus  with  the  peritoneum. 

Thus  there  are  three  situations  in  the  uterus  where  my- 
omata may  arise — (i)  In  the  true  uterine  tissue:  such  are 
said  to  be  intramural  or  interstitial  myomata.  (2)  In  the 
mucous  membrane  :  these  are  called  submucous  myomata. 
(3)  In  the  subperitoneal  tissue :  these  are  termed  subserous 
myomata. 

Myomata  may  arise  in,  and  remain  confined  to,  any  one 

isi 


I  82 


DISEASES   OF   WOMEN. 


of  these  layers,  or  they  may  arise  in  all  three  situations  in 
the  same   individual. 

I.  Intramural  Myomata. — These  maybe  single  or  mul- 
tiple; in  their  early  stages  they  resemble,  in  section,  knots 
in  a  piece  of  wood.     These  tumors    ha\'e   ilistinct   capsules 


Fig.  59. — Uterus  in  sagittal  section,  showing  intr.imiiral  and  subserous  myomata. 

and  are  firm  and  even  hard  to  the  touch.  The  bundles  of 
muscle-fibres  are  often  interwoven  in  such  a  manner  that 
they  present  a  characteristic  whorled  appearance.  Myom- 
ata arise  in  any  part  of  the  uterine  wall  (Fii;.  59).  but  they 
are  more  frequent  in  the  body  or  the  fundus  than  in  the 


DISEASES   OF  THE    UTERUS.  1 83 

cervix  (Fig-.  60).     Tiicrc  is  no  limit  to  their  growth,  and 


Fig.  60.  —  liilracervic.'il  myoma  in  sagittal  section. 

they  may  attain  gigantic  proportions  (twenty  or  even  thirty 
kilogrammes). 

In    texture    they   vary  greatly.     Some    are    as    hard   as 


i84 


DISEASES   OE   WOMEN. 


cartilage ;  these  contain  a  large  proportion  of  fibrous  tis- 
sue (fibro-niyoniata)  and  grow  slowly.  Sonic  arc  as  soft  as 
a  fatt)'  tumor,  and  consist  of  large  cells  ;  these  are  very 
xascular  and  grow  rapidly.  Some  of  these  intramural 
m)oniata  are  so  rich  in  blood-vessels  that  on  section  they 
look  not  unlike  cavernous  najvi  (Fig.  6i).  Such  tumors 
furnish  a  loud  venous  hum  on  auscultation. 


KiG.  6i. — A  very 


sciilar  myoma  in  ^cciioii  i\'mh.\\  ) 


Sometimes  a  myoma  confined  to  one  wall  of  the  uterus 
will  appear  as  a  simple  tumor,  but  on  section  it  will  be 
found  to  consist  of  two  or  more  tumors,  each  possessing 
its  own  capsule. 

2.  Submucous  Myoviatn. — These  tumors  arise  in  the 
deeper  layers  of  the  mucous  membrane,  and,  as  soon  as  they 
attain  an  appreciable  size,  project  into  the  uterine  cavity. 
Many  of  them  remain  sessile,  but  the  majority  tend  to  be- 


DISEASES   OF   THE    UTERUS. 


1 85 


come  -Stalked,  and  arc  then  termed  polypi.  Whether  sessile 
or  stalked,  they  are  invested  by  the  uterine  mucous  mem- 
brane. The  presence  of  a  myoma  in  the  wall  c)f  the  uterus 
or  projectini^  into  its  cavity  leads  to  great  thickening  of  the 
uterine  wall,  accompanied  by  increased  vascularity,  which  is 
often  manifested  by  menorrhagia  and  intermenstrual  hemor- 
rhage— metrorrhagia. 

The  pedicle  of  a  submucous  myoma  may  be  long  enough 
to  allow  the  tumor  to  be  extruded  into  the  vagina  (Fig.  62), 


Fig.  62. — Uterus  opened  anteriorly  to  show  two  peduncul.ited  myomata  :  the  larger  projects 

into  the  vagina. 

and  it  may  present  itself  at  the  vulva.  When  this  happens 
an  interesting  change  takes  place  in  the  character  of  the 
epithelium  of  the  extruded  part.  So  long  as  the  tumor 
remains  within  the  cavity  of  the  uterus,  the  mucous  mem- 
brane covering  it  is  indistinguishable  from  that  lining,  the 
cavity  of  the  uterus,  and  the  surface  epithelium  as  well  as 
that  lining  the  recesses  of  the  glands  is  of  the  columnar 
ciliated  variety.  When  the  myoma  enters  the  vagina  the 
epithelium    covering   the   extruded   portion    becomes  con- 


1 86  DISEASES   OE  WOMEN. 

verted  into  stratified  epithelium  on  all  those  portions  sub- 
ject to  pressure,  but  the  epithelium  in  the  ^dandular  re- 
cesses remains  columnar  and  ciliated. 

The  extrusion  of  a  myoma  through  the  cervical  outlet 
sometimes  ends  in  its  complete  detachment ;  this  is  of 
course  curative.  More  often  the  extrusion  leads  to  sec- 
ondary changes  inimical  to  life.  When  a  stalked  myoma 
escapes  from  the  cervical  canal,  its  pedicle  is  firmly  grasped 
by  the  cervix;  this  interferes  with  the  circulation  in  the 
tumor,  leading  to  marked  oedema  of  the  myoma  and  to 
gangrene;  the  dead  mass  becomes  infected  with  micro- 
organisms, decomposes,  and  sets  up  septic  changes  in  the 
uterus,  leading  to  sloughing  of  the  endometrium,  salpingitis, 
peritonitis,  and  the  usual  dread  sequences. 

3.  Subserous  JMyoinnta. — It  is  rare  for  myomata  arising  in 
the  subserous  stratum  to  attain  large  dimensions.  Like 
the  submucous  variety,  they  quickly  become  pedunculated. 
As  many  as  fifteen  or  twenty  of  these  bodies  may  be 
counted  on  the  peritoneal  surface  of  the  uterus,  varying  in 
size  from  a  pea  to  a  walnut.  Such  myomata  rarely  cause 
inconvenience,  and  are  often  found  after  death  in  individuals 
in  whom  their  presence  has  never  even  been  suspected. 
Large  single  pedunculated  subserous  myomata  weighing  half 
a  kilogramme  sometimes  cause  trouble  from  the  mechanical 
effects  they  are  liable  to  produce.  Any  of  these  varieties 
may  occur  together  in  the  same  uterus  ;  indeed,  it  is  usual 
to  find  subserous  and  intramural  myomata  associated.  In- 
tramural tumors  are  often  present  alone ;  but  it  is  by  no 
means  rare  to  find  moderately  large  examples  in  the  uterine 
walls  accompanied  by  a  small  submucous  myoma ;  and  the 
latter  is  far  more  frequently  the  source  of  dangerous  hemor- 
rhage and  pain  than  its  large  companion.  Sessile  sub- 
serous myomata  sometimes  attain  prodigious  proportions 
(5  kilos). 

Secondary  Changes. — The  chief  are — Mucoid  degen- 
eration ;  fatty  metamorphosis  ;  calcification  ;  septic  infection. 


DISEASES   OE   THE    UTERUS.  1 8/ 

Mucoid  Dcgoicration. — Large  myomata  are  especially 
prone  to  soften  in  the  centre,  whereby  lar_<(e  tracts  of  tissue 
become  converted  into  mucin.  When  this  change  takes 
place  extensively,  the  tumor  resembles  a  cyst ;  it  is  then 
often  termed  a  "  fibro-cystic  tumor  "  of  the  uterus.  The 
actual  conversion  of  the  tumor  substance  is  preceded  by 
oedema  of  the  connective  tissue,  and  the  cells  assume  the 
spider-like  shape  characteristic  of  myxomatous  cells ;  then 
it  becomes  as  structureless  and  diffluent  as  vitreous  humor. 

Fatty  Metamorphosis. — This  change  is  rarer  than  the  pre- 
ceding. A  localized  collection  of  fat  has  been  found  in  the 
centre  of  a  pedunculated  submucous  myoma. 

Calcification. — Old  uterine  myomata,  large  and  small,  are 
liable  to  become  infiltrated  with  lime  salts.  The  deposit 
does  not  take  place  in  an  irregular  manner  in  the  tissues  of 
the  tumor,  but  corresponds  to  the  disposition  of  its  fibres. 
On  examining  the  sawn  surface  of  a  completely  calcified 
uterine  myoma,  the  whorled  arrangement  of  the  fibres  is  so 
completely  reproduced  as  to  leave  no  doubt  as  to  the  nature 
of  the  mass.  When  these  calcified  tumors  are  macerated  and 
the  decayed  tissues  washed  away,  the  calcareous  matter  re- 
mains as  a  coherent  skeleton  of  the  tumor.  Such  changes 
have  actually  taken  place  whilst  the  tumor  remained  in  the 
living  uterus  ;  they  were  formerly  termed  "  uterine  calculi," 
and  when  found  in  coffins  in  old  burying-grounds  are  some- 
times imagined  to  be  very  large  vesical  calculi. 

A  subserous  myoma  is  very  prone  to  calcify,  and,  if  its 
stalk  be  thin,  is  apt  to  be  twisted,  and  the  tumor,  becoming 
detached,  falls  into  the  coelom  and  finds  it  way  into  all  sorts 
of  queer  recesses.  A  detached  nodule  of  this  sort  may 
tumble  into  a  hernial  sac. 

Septic  Infection. — It  occasionally  happens  that  a  myoma 
which  has  existed  many  years  and  given  rise  to  little  incon- 
venience, suddenly  enlarges,  assumes  formidable  propor- 
tions and  causes  severe  constitutional  disturbance.  These 
changes  are  due  to  septic  infection  which  ma\-  follow  injury 


1 88  DISEASF.S   OF   WOMEN. 

in  the  course  of  a  clinical  examination  or  attempts  at  re- 
moval ;  it  may  become  infected  from  a  hollow  viscus  like 
the  bladder  or  intestine.  Occasionally  the  changes  super- 
vene on  labor  or  abortion. 

The  appearance  of  an  infected  myoma  is  very  striking;. 
On  section  it  looks  cedematous  and  exhales  a  sickly  od<jr. 
On  microscopic  examination  the  muscle-cells  are  .separated 
by  multitudes  of  leucocytes,  and  micro-or^^anisms  are  de- 
monstrable in  the  tissue. 

Sections  of  an  inflamed  myoma  under  the  microscope  re- 
semble very  closely  sarcomatous  tissue,  and  there  is  little 
doubt  that  many  specimens  described  as  "  sarcomatous  " 
or  "  maliij^nant  "  degeneration  of  "  uterine  fibroids  "  were 
of  this  nature. 

Malignant  Changes. — The  conversion  of  innocent  into 
malignant  tumors  is  a  matter  surrounded  by  clouds  of  un- 
certainty, but  there  are  some  clearly  described  cases  in 
which  secondary  tumors  have  occurred  in  the  lungs,  fur- 
nishing the  histologic  features  of  myomata,  and  a  large  my- 
oma has  occupied  the  uterus. 

Impaction. — A  myoma  is  said  to  be  impacted  when  it 
fits  the  true  pelvis  so  tightly  that  it  presses  upon  the  rec- 
tum and  urethra.  Occasionally  a  mj'oma  may  be  so  firmly 
fixed  in  the  pelvis  that-  it  cannot  be  displaced  by  pressure 
applied  through  the  vagina  (Fig.  63). 

There  is  a  form  of  temporaiy  impaction  to  which  myom- 
ata in  women  between  thirty-five  and  fifty  are  liable.  A 
myoma  may  be  of  such  a  size  that  it  is  easily  accommo- 
dated in  the  pelvis,  without  pressing  injuriously  on  the 
urethra  or  rectum,  during  the  intermen.strual  period.  A  ^cw 
days  before  the  flow  appears  the  myoma  becomes  turgid, 
and  this  increase  is  sufficient  to  cause  the  tumor  to  press  on 
the  urethra  and  cause  retention  of  urine,  demanding  the  use 
of  a  catheter;  as  soon  as  the  flow  apjjcars  the  urethra  is  set 
free. 

Impaction,  whether   temporary   or   permanent,   leads  to 


DISEASES   OF   THE    UTEIWS. 


189 


baleful  affects  on  the  bladder,  ureters,  and  kidneys.  Very 
large  uterine  myomata  rising  high  in  the  belly  will  lead  to 
dangerous   complications  by  pressing  on   the  ureters   and 


Fig.  63. — Pelvis  in  sagittal  section,  showing  an  impacted  uterine  myoma. 


rectum  at  the  pelvic  brim.     Sometimes  such  tumors  press 
on  the  iliac  veins  and  cause  oedema  of  the  lower  limb. 

Uterine  Myomata  and  Pregnancy. — The  coexistence 
of  a  myoma  in  the  uterus  and  pregnancy  is  often  a  serious 
condition,  the  gravity  of  the  association  depending  largely 
upon  the  situation  of  the  tumor  (Fig.  64).  For  example, 
an  interstitial  myoma  may  rapidly  grow  in  correspondence 
with  the  increasing  size  of  the  uterus  due  to  pregnancy. 
The  presence  of  the  tumor  may  induce  abortion,  and  as 
the  uterus  involutes  the  myoma  may  disappear. 


190  DISEASES   OE   WOMEN. 

Abortion  complicated  by  a  myoma  greatly  imperils  the 
mother's   life  from  bleeding. 

When  the  tumor  is  of  the  subserous  variety  and  pedun- 
culated it  is  apt  to  become  oedematous  and  mechanically 


Tube.         Placenta.  Amnion. 


Fig.  64. — Gravid  uterus  (tliird  iiionih)  willi  multiple  myomata. 

interfere  with   the  ascent   of  the   uterus.     In  such  a  case 
abortion  is  the  rule. 

When  a  myoma  occupies  the  cer\-ix  it  offers  mechanical 
obstruction  to  the  transit  of  the  foetus,  and  a  submucous 
polypus  may  be  driven  out  of  the  uterus  in  front  of  the 
presenting  part.  A  sessile  submucous  mx'oma  may  not  in- 
terfere with  pregnancy  or  delivery,  but  a  sessile  subserous 


DISEASES   OF   THE    UTERUS.  I9I 

myoma  near  the  neck  of  the  uterus  would  offer  an  insuper- 
able barrier  to  deliveiy  at  or  near  term. 
The  Chief  Causes  of  Death. — These  are — 

1.  Hcuiorrliagc. — Copious  loss  of  blood  may  be  a  cause 
of  death  ;  frequent  bleeding  produces  extreme  anaemia,  which 
may  indirectly  lead  to  fatal  complications. 

2.  Mechanical  Effects. — Intestinal  obstruction  may  result 
from  pressure  on  the  rectum,  or  a  loop  of  small  bowel  may 
become  entangled  by  the  stalk  of  a  pedunculated  myoma. 
Pressure  on  urethra  or  ureters  may  lead  to  cystitis,  saccu- 
lated kidneys,  nephritis,  or  hydronephrosis  and  pyonephrosis. 

3.  Pregnancy  in  a  myomatous  uterus  may  terminate  hap- 
pily ;  more  often  it  leads  to  abortion  and  imperils  life  from 
bleeding.  A  myoma  may  disappear  during  involution  of 
the  uterus. 

4.  Sepsis. — A  gangrenous  myoma  may  infect  the  uterus 
and  establish  fatal  septicaemia;  purulent  material  may  travel 
along  the  Fallopian  tubes  and  set  up  fatal  peritonitis. 


CHAPTER    XXII. 

DISEASES   OE  THE   UTERUS   (Continued). 

THE    CLINICAL    CHARACTERS   AND    TREAT- 
MENT  OF    MYOMATA. 

Clinical  Characters. — Uterine  myomata,  the  com- 
monest genus  of  innocent  tumors  to  which  women  are 
hable,  are  unknown  before  puberty,  and  rarely  attract 
attention  until  the  twenty-fifth  year;  from  this  age  they 
increase  in  frequency,  and  are  most  common  between 
the  thirty-third  and  fifty-fifth  years.  Hard  myomata  usu- 
ally cease  to  grow  after  the  menopause ;  some  shrink  at 
this  period,  but  the  majority  remain  in  statu  quo  and  some 
slowly  calcify.  Occasionally  a  soft  myoma  will  grow  very 
rapidly  after  the  menopause. 

Syuiptoms. — In  a  v^xy  large  proportion  of  cases  the  earliest 
indication  of  a  myoma  in  the  uterus  is  excessive  menstru- 
ation (menorrhagia),  ajid  this  may  be  complicated  b}'  ute- 
rine bleeding  between  the  menstrual  periods  (metrorrhagia). 
These  hemorrhages  are  often  the  only  .symptom  which  leads 
the  patient  to  seek  advice,  and  on  examination  a  large  pel- 
vic tumor  may  be  detected.  In  many  cases  there  is  no  ob- 
vious enlargement  of  the  uterus,  and  the  existence  of  a 
small  submucous  myoma  (polypus)  is  a  matter  of  presump- 
tion founded  on  clinical  experience,  only  proved  or  dis- 
proved by  dilating  the  cervical  canal  and  exploring  the 
cavity  of  the  uterus.  In  many  cases  when  the  patient 
seeks  advice  the  myoma  is  actually  presenting  at  the 
mouth  of  the   uterus. 

When  the  myoma  is  so  large  as  to  rise  out  of  the  pelvis 

192 


DISEASES   OF  THE    UTERUS.  1 93 

it  usually  occupies  the  hypof^astric  region,  but  if  peduncu- 
lated it  may  lie  in  tlie  Hanks  and  simulate  an  ovarian  tumor. 
To  i)alpation  it  may  be  smooth,  but  when  the  surface  is 
tuberose  it  is  a  valuable  sign.  Auscultation  sometimes 
furnishes  valuable  evidence,  for  a  soft,  rapidly-growing  my- 
oma often  yields  a  loud  venous  hum  synchronous  with  the 
pulse  and  indistinguishable  from  the  uterine  souffle  heard  in 
pregnancy.  This  hum  may  be  present  a  few  days  before  the 
onset  of  menstruation,  and  disappear  as  soon  as  the  flow 
occurs,  to  reappear  immediately  before  the  next  menstrual 
period. 

On  vaginal  examination  the  tumor  will  be  found  closely 
associated  with  the  uterus.  The  body  and  cervix  may  form 
part  of  a  globular  mass,  the  mouth  of  the  womb  being  indi- 
cated by  a  small  dimple. 

The  sound  often  gives  great  assistance ;  in  the  majority 
of  cases  myomata  lead  to  enlargement  of  the  cavity  of  the 
uterus.  The  sound  facilitates  localization  of  the  tumor,  and 
often  enables  the  surgeon  to  determine  whether  the  uterus 
is  involved  partially  or  entirely. 

The  employment  of  the  sound  demands  extreme  care :  a 
myomatous  uterus  is  sometimes  gravid.  When  free  bleed- 
ing follows  very  gentle  use  of  this  instrument,  it  is  often  an 
indication  that  there  is  a  submucous  tumor  projecting  into 
the  uterine  cavity. 

The  chief  conditions  which  complicate  the  diagnosis  of 
large  uterine  myomata  are  pregnancy  and  ovarian  tumors  ; 
the  latter  are  fully  discussed  in  Chapter  XXXII. 

In  some  cases  the  detection  of  uterine  myomata  is  simple 
and  certain  ;  in  others  the  wisest  and  most  experienced  find 
great  difficulties  in  the  way  of  exact  diagnosis. 

Diflferential  Diagnosis  of  Pregnancy  and  Myom- 
ata.— Tumors  of  the  internal  genital  organs  of  women  are 
most  frequent  during  the  sexual  period  of  life — from  the 
fifteenth  to  the  forty-fifth  year;  and,  as  many  species  of 
tumors  (so  far  as  rate  of  growth  and  size  are  concerned) 

13 


194  DISEASES   OF   1^0 MEN. 

simulate  pregnancy,  and  vice  versa,  it  naturally  behoves 
every  surgeon  to  make  himself  familiar  not  only  with  the 
signs  of  normal  gestation,  but  with  the  abnormal  forms  as 
well.  It  is  also  important  to  remember  that  his  professional 
reputation  may  be  wrecked,  and  a  single  woman's  social 
position  may  be  ruined  by  such  a  blunder  as  attributing  the 
enlargement  of  her  belly  to  a  gravid  uterus  when  it  is  due 
to  an  ovarian  or  a  uterine  tumor. 

It  will  be  convenient  to  discuss  the  diagnosis  of  preg- 
nancy under  the  following  headings :  Normal  Pregnancy ; 
Hydramnion  ;  Retroversion  of  a  Gravid  Uterus;  Cornual 
Pregnancy;  Extra-uterine  Pregnancy  (see  Chapter  XXVII.). 

I.  Normal  Pregnancy. — In  the  case  of  a  married 
woman  at  the  childbearing  period  of  life  under  usual  cir- 
cumstances there  is  little  danger  of  error;  but  a  married 
woman  with  a  rapidly-growing  uterine  or  ovarian  tumor 
may  imagine  herself  pregnant,  and  even  arrange  for  the 
advent  of  the  baby  and  have  the  nurse  ready  to  receive  it. 

The  following  constitute  a  group  of  signs  of  pregnancy 
which,  if  carefully  sought  for,  rarely  mislead  : 

1.  Amenorrhcea. 

2.  Fulness  of  the  breasts,  with  the  presence  of  milk. 

3.  Pigmentation  of  the  mammary  areolae. 

4.  The  soft  tumor  in  the  hypogastrium  which  hardens 
and  softens  under  firm,  continued  pressure  of  the  palm. 

5.  Movement  of  the  foetus. 

6.  Ballottement. 

7.  Softness  of  the  cervix. 

8.  The  fostal  heart  and  the  uterine  soufHe. 

The  cases  which  give  rise  to  difficulty  are  those  in  which 
individuals  have  motives  for  concealing  their  pregnancy,  or 
cases  in  which  there  is  some  abnormal  condition  of  the 
foetus  or  its  membrane,  or  tumors  in  addition  to  pregnancy. 
It  is  also  important  to  remember  that  women  may  conceive 
even  as  late  as  their  fifty-ninth  year.  In  the  first  set  of 
cases  it  is  ea.sy  to  recall   instances  in  illustration   of  "  the 


DISEASES   OF   THE    UTERUS.  1 95 

pertinacity  and  apparent  innocence  "  with  which  unmarried 
women  will  sometimes  deny  the  possibility  of  pregnancy 
even  when  they  are  actually  in  labor. 

In  cases  of  unmarried  women  the  greatest  caution  is 
necessary  before  expressing  an  opinion  that  the  case  is  one 
of  pregnancy ;  by  a  little  waiting  the  case  settles  itself,  and 
in  doubtful  conditions  nothing  is  to  be  gained  by  giving  an 
opinion  straight  away,  whereas  two  months  is,  as  a  rule, 
sufficient  to  lead  the  patient  to  thoroughly  realize  her  con- 
dition, and  she  may  not,  in  the  circumstances,  deem  it  ne- 
cessary to  trouble  the  surgeon  a  second  time. 

Two  rules  should  be  observed  in  dealing  with  cases  of 
suspected  pregnancy:  (i)  When  in  doubt,  defer  expressing 
an  opinion,  and  see  the  patient  again  after  a  few  weeks'  in- 
terval. (2)  Never  pass  a  sound  zvhcre  there  is  even  a  sus- 
picion of  pregnancy. 

II.  Hydramnion. — This  complication  of  pregnancy  has 
many  times  been  mistaken  for  a  large,  rapidly  growing 
ovarian  cyst.  The  trouble  consists  in  the  accumulation  of 
an  excessive  quantity  of  amniotic  fluid.  Usually  the  gesta- 
tion proceeds  normally  till  near  the  seventh  month ;  then 
the  belly  increases  in  size  in  a  rapid  manner  and  causes 
great  inconvenience  and  distress.  CHnically  the  enlarge- 
ment furnishes  the  signs  of  a  very  large  ovarian  cyst. 

Should  there  be  any  difficulty  in  the  diagnosis  as  between 
hydramnion  and  a  pelvic  tumor,  the  employment  of  the 
uterine  sound  will  settle  the  difficulty.  It  will  probably 
terminate  the  pregnancy,  but  this  is  preferable  to  an  ab- 
dominal section  made  under  the  supposition  that  the  patient 
has  a  tumor.  The  amount  of  fluid  present  in  cases  of  hy- 
dramnion is  sometimes  almost  incredible  and  may  amount 
to  many  litres.  Hydramnion  is  usually  associated  with 
twins.  Ballottcment  is,  as  a  rule,  not  only  easily  obtained, 
but  unusually  distinct. 

III.  Retroversion  of  the  Gravid  Uterus. — This  means 
that  the  fundus  of  the  uterus  is  lodeed  in  the  hollow  of  the 


196  DISEASES   OF   WOMEN. 

sacrum,  and  is  prcvciitcd  from  risin^^  on  account  of  the 
sacral  promontory.  As  the  uterus  enlarges  the  cervix  is 
raised  and  pushed  forward,  compresses  the  urethra,  and 
causes  retention,  often  accompanied  by  incontinence  (ischuria 
paradoxica).  The  clinical  si^rns  of  a  gravid  uterus  in  this 
condition  are  very  decided.  First,  there  is  the  presence  of 
an  oval  hypogastric  tumor  (the  over-full  bladder);  a  history 
of  prci^nancy  between  the  third  and  fourth  months;  and  on 
examination  a  rounded  elastic  swelling  (the  body  of  the 
uterus  occupying  the  hollow  of  the  sacrum)  will  be  felt, 
whilst  the  cervix  lies  behind  the  pubes,  and  sometimes  so 
high  that  the  finger  can  hardly  reach  it.  On  passing  a 
catheter  and  emptying  the  bladder  the  hypogastric  tumor 
disappears.  On  examining  the  abdomen  bimanually  the 
fundus  of  the  uterus  cannot  be  detected  anteriorly.  These 
facts  serve  to  distinguish  an  incarcerated  uterus  from  a 
uterine  myoma,  tubal  pregnancy,  or  ovarian  tumor.  The 
diagnosis  is  usually  verified  by  rectifying  the  position  of  the 
uterus.  After  emptying  the  bladder,  upward  pressure  on 
the  uterus  through  the  vagina  or  the  rectum  will  cause  it 
to  ascend.  Sometimes  it  will  be  necessary  to  administer 
an  anaesthetic  in  order  to  effect  the  replacement. 

IV.  Cornual  Pregnancy. — It  is  pointed  out  in  Chap- 
ter V.  that  the  uterus  sometimes  presents  the  bicorned 
condition  characteristic  of  many  mammals,  such  as  cows, 
mares,  and  ewes.  It  is  well  established  that  a  bicorned 
uterus  in  women  may  become  gravid,  the  pregnancy  go  to 
term,  and  delivery  terminate  as  happily  as  in  an  organ  of 
normal  shape.  When  one  horn  only  is  gravid — and  this  is 
the  usual  condition — the  non-gravid  cornu  enlarges  and  a 
decidua  is  developed  within  it.  When  a  woman  with  a  bi- 
corned uterus  comes  under  observation  in  the  early  stages 
of  pregnancy  and  is  submitted  to  physical  examination, 
there  is  great  probability  that  the  unilateral  position  of  the 
enlarged  cornu  will  lead  to  an  erroneous  diagnosis,  and  sev- 
eral cases  have  been  recorded  in  which,  under  the  supposi- 


DISEASES   OF   THE    UTERUS.  1 97 

tion  that  the  patient  was  suffering  from  an  ovarian  tumor, 
uterine  myoma,  or  tubal  pregnancy,  cceliotomy  has  been 
performed.  In  some  instances  the  gravid  half  of  the  uterus 
has  been  amputated  before  the  nature  of  the  condition  was 
appreciated. 

There  is,  however,  a  variety  of  cornual  gestation  of  deep 
interest  to  the  surgeon.  When  an  oosperm  lodges  in  the 
rudimentary  cornu  of  what  is  known  as  the  "  unicorn 
uterus"  (Fig.  21,  p.  63),  gestation  may  proceed  without 
inconvenience  for  three  or  more  months,  but,  as  delivery 
by  the  natural  passages  is  impossible,  the  ultimate  results 
are  similar  to  those  of  tubal  pregnancy. 

The  clinical  signs  of  gestation  in  the  rudimentary  horn 
of  a  unicorn  uterus  are  those  of  tubal  pregnancy,  and  in 
many  instances  even  during  the  post-vwrtcm  inspection  the 
nature  of  the  lesion  is  overlooked. 

The  relation  of  the  round  ligament  to  the  gestation  sac 
forms  a  ready  means  of  distinction  between  a  gravid  Fallo- 
pian tube  and  a  cornual  pregnancy : 

(i)  In  a  normal  uterus  the  round  ligament  springs  from 
the  upper  angle,  immediately  in  front  of  the  tube. 

(2)  In  tubal  gestation  the  round  ligament  is  attached  to 
the  body  of  the  uterus  on  the  uterine  side  of  the  gestation 
sac. 

(3)  In  cornual  pregnancy  the  round  ligament  is  situated 
on  the  outer  side  of  the  gestation  sac. 

Pregnancy  in  the  rudimentary  cornu  of  a  unicorn  uterus 
runs  a  different  course  to  tubal  pregnancy.  In  the  case  of 
the  tube,  rupture  (or  abortion)  usually  occurs  before  the 
twelfth  week,  whereas  in  cornual  pregnancy  the  gestation 
may  go  on  to  full  term,  and  then  ineffectual  labor  leads  to 
the  death  and  subsequent  mummification  of  the  foetus  ;  or 
the  gestation  sac  may  rupture  at  any  period  from  the  sec- 
ond to  the  ninth  month. 

The  pregnant  cornu  of  a  unicorn  or  of  a  bicorned  uterus 
may  undergo  axial  rotation. 


198  DISEASES   OF   VVOMKX. 

Treatment  of  Myomata.— W'licn  a  small-stalked  poly- 
pus aj)pcars  at  the  iiioiitli  of  the  womb  it  is  casil)'  dealt  with. 
The  vai,nna  is  douched  with  an  antiseptic  s(jlution  and  the 
tumor  seized  with  a  stout  volsella  and  gently  twisted  off 

When  the  pedicle  is  thick  it  should  be  cut  with  scissors. 
Some  operators  prefer  to  divide  tile  stalk  with  a  wire  snare  or 
an  ecraseur,  a  contrivance  rapidly  disappearing  from  surgery. 

Often  the  presence  of  a  submucous  myoma  is  conjec- 
tural ;  then  the  cervical  canal  is  dilated  sufficiently  to  allow 
the  uterine  cavity  to  be  explored  with  the  finger.  Small 
myomata  thus  discovered  are  often  easily  seized  with  for- 
ceps and  detached.  Larger  sessile  myomata  require  more 
deliberate  treatment.  It  is  sometimes  necessary  to  split  the 
capsule  of  the  tumor  and  then  enucleate  it  with  the  finger. 
The  myoma  may  then  be  gripped  with  a  stout  volsella  and 
gently  rotated  out  of  its  bed.  When  the  base  of  a  submu- 
cous myoma  is  very  broad  it  demands  great  prudence  in 
operating. 

It  occasionally  happens  that  a  myoma  is  detached  in 
this  way,  but  it  is  too  large  to  be  withdrawn  through  the 
cervical  canal.  Under  such  conditions  three  courses  are 
open  to  the  surgeon  :  He  may  either  freely  incise  the  cer- 
vix bilaterally,  or  the  bladder  may  be  turned  off  the  an- 
terior aspect  of  the  cervix  and  the  cervical  wall  cut  through 
in  the  middle  line  anteriorly  as  high  as  the  internal  os.  This 
will  easily  allow  of  the  delivery  of  the  tumor,  and  the  cer- 
vical incision  is  closed  with  sutures.  Or  the  tumor  may  be 
removed  piecemeal  with  scissors  and  forceps  (morcelle- 
ment).  By  whichever  method  the  patient  is  deprived  of  the 
myoma,  the  uterine  cavity  is  flushed  with  water  at  1 10°  F., 
which  quickly  causes  the  uterus  to  contract  and  bleeding 
to  cease.  The  cavity  is  lightly  plugged  with  gauze  and 
the  vagina  tamponed. 

The  plugs  are  withdrawn  in  twenty-four  hours  ;  warm 
douching  is  employed  twice  daily,  and,  in  the  majority  of 
patients,  recovery  is  rapid  and  complete. 


DISEASES   OF   THE    UTERUS.  1 99 

The  treatment  of  myomata  too  large  for  the  summary 
measures  just  detailed  demands  careful  consideration.  If 
these  large  tumors  could  be  removed  with  the  same  ease 
and  safety  as  ovarian  tumors,  there  could  be  no  doubt  as  to 
the  advisability  of  surgical  treatment.  The  removal  of  a 
myomatous  uterus  through  an  incision  in  the  belly-wall  is 
a  grave  proceeding  even  in  the  hands  of  dextrous  and  ex- 
perienced operators.  Each  year,  happily,  results  continue 
to  improve,  and  there  are  hopeful  signs  that  the  chances  of 
success  will  soon  equal  those  of  ovariotomy. 

The  measures  fall  under  three  headings:  i.  Oophorec- 
tomy ;  2.  Myomectomy ;  3.  Hysterectomy.  The  indications 
for  adopting  one  or  other  of  these  proceedings  will  now  be. 
given. 

It  has  already  been  mentioned  that  myomata  cease  to 
grow,  and  even  shrink,  after  the  menopause.  Taking  ad- 
vantage of  this  fact,  surgeons  often  anticipate  the  menopause 
by  removing  the  ovaries  (oophorectomy).  This  method  is 
not  applicable  to  all  cases,  for  in  many  the  ovaries  are  so 
involved  in  the  tumor  that  they  cannot  be  completely  re- 
moved, and  if  only  a  portion  of  an  ovary  be  left  menstrua- 
tion continues  and  nullifies  the  operation.  Many  attempted 
oophorectomies  have  terminated  in  hysterectomy.  It  is  the 
rule  not  to  interfere  with  uterine  myomata  unless  they  di- 
rectly threaten  the  patient's  life.  Oophorectomy  for  my- 
omata is  being  rapidly  superseded  by  hysterectomy. 

The  following  rules  in  regard  to  the  surgical  treatment 
of  uterine  myomata  may  be  useful : 

(i)  A  myoma  is  the  cause  of  serious  and  repeated  bleed- 
ing, producing  profound  anaemia ;  the  bleeding  is  uninflu- 
enced by  rest  and  the  administration  of  ergot.  When  these 
troubles  are  not  due  to  a  pedunculated  myoma  projecting 
into  the  uterine  cavity,  and  the  menopause  cannot  be  reason- 
ably expected  for  two  or  three  years,  oophorectomy  should 
be  performed ;  failing  this,  hysterectomy,  if  the  anatomical 
conditions  are  favorable. 


2(X>  DISEASES   OF   WOMEN. 

(2)  A  myoma  of  moderate  size  in  a  woman  between 
thirty  and  forty-five  becomes  impacted  and  causes  reten- 
tion of  urine  at  each  menstrual  period.  Such  a  case  is  very 
suitable  for  oophorectomy. 

The  following  conditions  demand  hysterectomy  : 
(i)  A  myoma  rapidly  increasing  in  size  and  extending 
high  above  the  pelvic  brim  and  pressing  on  the  colon,  so 
as  to  cause  intestinal  obstruction. 

(2)  A  myoma  rapidly  enlarging  after  the  menopause. 

(3)  A  fibro-cystic  myoma. 

(4)  A  myoma  that  has  given  little  trouble  suddenly  be- 
gins to  enlarge  rapidly,  accompanied  by  rapid  pulse,  high 
temperature,  and  signs  of  septicaemia.  These  signs  indicate 
septic  infection  of  the  tumor.  A  gangrenous  myoma  should 
be  removed  without  delay ;  occasionally  a  gangrenous  myo- 
ma is  too  large  to  be  removed  through  the  vagina,  and  re- 
quires abdominal  hysterectomy. 

(5)  The  large  pedunculated  myomata,  which  simulate 
ovarian  tumors,  may  be  easily  dealt  with  by  transfi.xion  and 
ligature  of  their  pedicles  (abdominal  myomectomy). 

There  are  several  methods  of  performing  hysterectomy : 
the  steps  of  each  are  given  in  detail  in  the  chapter  devoted 
to  this  operation. 

Myomata  Complicating  Pregnancy. — As  uterine 
myomata  and  pregnancy  sometimes  coexist,  it  will  be  use- 
ful to  briefly  summarize  the  dangers  which  may  occur  with 
such  a  combination;  they  are — i.  Abortion;  2.  Mechanical 
impediment  to  deliveiy ;  3.  Free  bleeding  on  abortion  or 
delivery  at  term;  4.  A  subserous  myoma  may  inflame;  5. 
A  submucous  myoma  may  become  infected  and  necrose ; 
6.  Septicaemia. 

The  stages  when  some  of  the  above  troubles  may  arise 
and  the  appropriate  treatment  for  each  may  be  indicated  thus  : 

I.  During  Prcgnaticy. — It  may  be  necessary  to  induce 
labor;  to  enucleate  the  tumor  when  it  grows  from  the 
cervi.x ;  to  perform  abdominal   h)'stcrcctomy. 


DISEASES   OF   THE    UTERUS. 


20I 


2.  TIlc  Dijficulty  declares  itself  during  Labor. — It  may 
then  demand  hysterectomy. 

3.  Complications  during  the  Pucrpcrinvi. — These  may  re- 
quire abdominal  myomectomy  or  abdominal  hysterectomy. 

Polypi. — All  stalked  or  sessile  tumors  which  hang  from 
the  internal  wall  of  the  uterine  cavity  or  its  cervical  canal 
are  termed  polypi.  The  term  is  a  very  old  one,  and  has 
merely  a  chnical  significance. 

The  microscope  has  taught  us  that  polypoid  tumors  of 
the  uterus  belong  to  different  genera. 

The  hard  ''fibroid  polypi"  are  composed  of  unstriped 
muscle-fibre  and  fibrous  tissue:  they  are  niyoinata  ox  fibro- 
myoniata  (Fig.  62). 

The  soft  ''mucous  polypi"  consist  of  oedematous  con- 
nective tissue  in  which  glands 
may  be  scanty  or  abundant. 
These   are   adenomata  (Fig. 

65). 

Many  polypi  are  detached 
fragments  of  placenta,  and 
used  to  be  called  placental 
polypi  (Fig.  51). 

"  Malignant  polypi  " 
are  protruding  or  fungating 
processes  of  carcinoma  (can- 
cer). 

„-,,  .  f     •       1  /-      .  Fig.  65. — So-called  mucous  polypus  of  ihe 

There  is  one  clmical  feature  cervical  canai  (a.  e.  g.). 

common   to   all  varieties  of 

polypi,  except  occasionally  small  pedunculated  adenomata 
of  the  cervix,  and  this  is  irregular  loss  of  blood.  The  small 
cervical  polypus  (Fig.  65),  even  when  it  does  not  cause 
bleeding,  often  produces  muco-purulent  discharge  from  the 
canal. 


C  li  A  V  T  !•:  R     XXII  I. 

DISEASES   OF   THE    UTERUS  (Continued). 

SARCOMA,  ADENOMA,   AND    CARCINOMA. 

Sarcoma. — The  tissue  of  the  uterus,  Hke  striped  and 
and  unstriped  muscle  in  other  regions  of  the  body,  is  occa- 
sionally the  seat  of  sarcoma,  sometimes  of  the  round-  and 
sometimes  of  the  spindle-celled  species.  The  uterus  differs 
from  a  muscle  in  the  important  fact  that  it  is  occupied  by  a 
cavity  lined  by  mucous  membrane  which,  during  sexual  life, 
is  very  active. 

Until  recently  it  was  believed  that  sarcomata  of  the  uterus 
were  somewhat  rare  :  this  error  may  be  attributed  to  the 
fact  that  in  clinical  work  it  is  so  customary  to  regard  malig- 
nant disease  of  the  uterus  as  the  equivalent  of  carcinoma 
that  no  steps  are  taken  to  verify  the  nature  of  the  disease 
by  histologic  methods. 

In  1893,  Sanger  and.  Pfeiffer  independently  described  a 
variety  of  uterine  sarcoma  which  in  its  microscopic  charac- 
ters so  strongly  resembled  decidual  tissue  that  it  has  be- 
come customary  to  speak  of  it  as  "  deciduoma."  However, 
the  records  of  a  large  number  of  similar  cases  have  been 
published,  which  make  it  clear  that  many  examples  of  ma- 
lignant disease  formerly  classed  as  "  uterine  cancer  "  are 
really  sarcomata  which  contain  a  large  number  of  cells 
similar  in  size  and  character  to  the  big  cells  found  in  the 
placenta  and  known  as  "  decidual  cells." 

Recent  observations  have  brought  to  light  the  important 
fact  that  sarcoma  of  this  variety  is  very  liable  to  occur  in 
the  endometrium  within  a  few  weeks  or  months  of  abortion 
202 


DISEASES   OE   THE    UTERUS. 


203 


or  delivery  at  term.  The  course  of  the  disease  is  marked 
by  oft-recurrin<r  profuse  hemorrhage,  great  emaciation,  en- 
largement of  tlie  uterus,  and  the  appearance  of  secondary 
nodules  in  the  thoracic  and  abdominal  viscera,  and  occa- 
sionally in  the  bones.  The  disease  is  fatal  and  runs  a  very 
rapid  course. 

The  uterus  is  enlarged,  and,  rising  out  of  the  pelvis,  gives 
rise  to  an  obvious  tumor  in  the  hypogastrium.     The  en- 


FiG.  66. — Sarcoma  of  uterus  (deciduoma)  (Sanger). 


largement  is  usually  nodular,  and  on  section  the  nodules  or 
bosses  are  filled  with  a  soft  reddish  mass  resembling  the 
pulp  of  a  pomegranate  (Fig.  66). 

Some  observers  hold  the  opinion  that  sarcomata  of  this 
variety  arising  shortly  after  a  labor  or  an  abortion  have 
their  origin  in  retained  fragments  of  decidua  or  placenta, 
but  the  evidence  is  not  sufficient  to  support  this  hypothesis. 


204 


DISEASES   OF   WOMEN. 


It  is  well  established  that  the  histologic  features  of  a  sar- 
coma are  largely  modified  by  its  environment,  and  as  very 
large  connective-tissue  cells  (decidual  cells,  Fig.  67)  are 
abundant  in  the  endometrium  of  a  gravid  uterus,  it  nat- 
urally follows  that  these  cells  would  be  conspicuous  in  a 
sarcoma  arising  in  a  uterus  recently  gravid. 

Sarcomata  occur  in  the  uterus  of  nulliparous  women,  and 
they  may  arise  in  the  cervix.  Pernice  has  described  a  very 
remarkable  example  which  involved  the  vaginal  portion  of 
the  cervix  (Fig.  68).  It  had  a  racemose  appearance,  the 
grape-like  bodies  being  composed  of  cells,  some  of  which 
were  oat-shaped ;  others  were  typical  spindles,  many  of 
them  presenting  a  cross  striation  indistinguishable  from  that 


.^#. 


Fig.  67. — A  group  of  decidual  cells. 

of  Striped  muscle  (Fig.  69).  In  the  basal  parts  of  the  tumor 
gland-like  spaces  exi.sted  lined  with  cylindrical  or  with  cu- 
bical epithelium.  (These  were  derived  from  the  glands  in 
the  cervical  endometrium.)  After  removal  this  tumor 
quickly  recurred  :  it  was  removed  a  second  time,  but  reap- 
peared and  rapidly  infiltrated  the  uterus,  forming  a  large 
mass ;  death  was  speedy.  On  microscopic  examination  of 
the  recurrent  tumor  no  striated  spindles  were  found,  and  the 
tumor  had  the  characters  of  a  simple  spindle-celled  sarcoma. 
Diagnosis. — It  is  rarely  possible  to  distinguish  in  the  early 
stages  between  a  sarcoma  and  a  carcinoma  of  the  body  of 
the  uterus.  It  is,  however,  an  important  fact  that  sarcoma 
of  the  uterus  is  more  apt  to  occur  during  the  childbearing 


DISEASES   01'    THE    UTERUS. 


205 


period  of  life,  whilst  cancer  of  the  body  of  the  uterus  is  un- 
common before  the  menopause. 

The  chief  signs  of  sarcoma  arc  frequent  bleedings  from  the 
uterus,  producing  great  anaemia  and  emaciation,  accompa- 


FiG.  68. — Sarcoma  of  the  cervix  uteri  (Pernice). 

nied  by  marked  enlargement  of  the  uterus.  When  these 
signs  follow  on  a  recent  labor  or  an  abortion,  they  are  sus- 
picious signs. 

It  is,  however,  certain  that  many  of  these  signs  are  caused 
by  retention  of  a  fragment  of  placenta  or  a  uterine  mole : 
under  such  conditions  the  cervical  canal  should  be  dilated, 
and  the  cavity  of  the  uterus  explored  and  an)'  retained  frag- 


306 


DISEASES   OF   WOMEN. 


mcnts  removed.  Should  a  morbid  product  other  than  pla- 
centa or  a  mole  be  detected,  it  is  desirable  to  reserve  pieces 
for  microscopic  examination. 

Treatment. — In  the  early  stages  of  uterine  sarcoma  vag- 
inal hysterectomy  gives  the  only  hope  of  cure. 


Mr 


?;^%j^^^^^OT 


Fig.  69  . — Microscopic  characters  of  a  uterine  sarcoma  containing  niusclc-ccUs  (Pcrnice). 

Bpithelioma. — This  disease  only  attacks  that  portion 
of  the  uterine  cervix  which  is  covered  by  an  extension  of 
the  vaginal  mucous  membrane.  It  may  begin  as  an  ulcer 
or  as  a  raised  warty  mass.  It  quickly  destroys  the  cervi.x 
and  involves  the  vaginal  mucous  membrane. 

Treatment. — When  the  patient  comes  under  obscrwition 
early — that  is,  while  the  epithelioma  is  restricted  to  the  cer- 
vix— amputation  of  the  cervix  gives  good  results.  It  is  im- 
portant to  bear  in  mind  that  operations  for  epithelioma  in 
this  situation  are  very  limited  by  the  close  proximity  of  the 


DISEASES   OF   THE    UTERUS. 


207 


bladder  to  the  anterior  surface  of  the  cervix.  Recurrence 
usually  takes  place  at  the  cut  edge  of  the  vaginal  mucous 
membrane. 

Amputation  of  the  cervix  uteri  for  epithelioma  is  attended 
with  a  very  small  risk  to  life. 

Adenoma. — This  genus  of  tumors  occurs  in  the  endo- 
metrium of  the  body  of  the  uterus  and  its  cervical  canal 


Iiijiltrdtcd  ovary. 


Uterine  cauity 


Wall  of  blad it) 


Cancer 


Cervical  canal 


Vagina 


Fig.  70. — Uterus  in  sagittal  section  with  carcinoma  of  the  cervix. 

(seep.  174).  The  condition  sometimes  described  as  "  ma- 
lignant adenoma "  of  the  body  of  the  uterus  is  carci- 
noma. 

Carcinoma. — It  will  be  necessary  to  consider  this  dis- 
ease in  two  sections ; 


208 


djsj:.is/:s  oi-  women. 


1.  Cancer  ori^nnatin^^  in  the  mucous  membrane  of  the  cer- 

vical canal  of  the  uterus ; 

2.  Cancer  arisin^r  jii  the  mucous  membrane  lining  the  uter- 

ine caxity. 
I.  Cancer  of  the  Cervical  Canal.— This  disease  is 
unfortunately  \cr\-  comnKjn,  and  may  begin  in  any  part  of 
the  mucous  membrane  lining  the  canal  (Fig.  70).  Careful 
observations  show  conclusively  that  the  disease  starts  in  the 
mucous  glands,  and  the  histologic  feature  of  the  cancerous 
mass  is  a  caricature  of  these  glands  (Fig.  71).     In  its  early 


Fig.  71. — Microscopic  characters  of  cancer  of  the  cervix. 

stages  the  disease  is  strictly  limited  to  the  cer\'ix,  but  it 
grows  quickly  and  infiltrates  the  connective  tissue  of  the 
mesometrium  (broad  ligaments),  the  vesico-vaginal  and 
recto-vaginal  septa.     The  surfaces  infiltrated  by  the  cancer 


DISEASES   OF  THE    UTERUS. 


209 


ulcerate  early  and  destroy  the  vaginal  portion  of  the  cer- 
vix, and  then  extend  to  the  supravaginal  parts  of  the  neck, 
and  finally  involve  the  body  of  the  uterus,  and  in  the  last 
stages  of  the  disease  this  organ  becomes  eroded  until 
nothing  but  a  thin  shell  remains. 

The  lymph-glands  in  the  course  of  the  iliac  vessels  are 
soon  infected,  and  finally  those  of  the  lumbar  set. 

Dissemination  is  frequent:  secondary  deposits  occur  in 
the  lungs  and  liver,  and  they  are  sometimes  met  with  in  the 
bones,  but  not  with  the  same  frequency  as  in  mammary 
cancer. 

Syuiptonis. — Cancer  of  the  uterine  neck  is  common  be- 
tween the  fortieth  and  fiftieth  years :  it  may  occur  as 
early  as  the  twenty-third  year,  but  between  twenty-three 
and  thirty  it  is  certainly  unusual. 

Like  uterine  myoma,  this  disease  belongs  especially  to 
the  latter  part  of  the  childbearing  period  of  life,  and  it  is 
almost  exclusively  confined  to  women  who  have  borne  at 
least  one  child. 

The  signs  of  cancer  are  bleeding,  offensive  vaginal  dis- 
charge, and  sometimes  pain.  The  first  two  are  the  signs 
which  usually  lead  women 
to  seek  advice. 

On  examination,  if  the  case 
is  in  its  early  stage,  the  edges 
of  the  OS  will  be  found  evert- 
ed (Fig.  72),  and  a  fungous 
mass  protrudes  from  the  ca- 
nal and  bleeds  on  the  slight- 
est touch.  Diagnosis  is  rare- 
ly difficult. 

Conditions  sometimes  mis- 
taken for  cancer  are  aden- 
omatous disease  of  the  cer- 
vical endometrium   (erosion)   and   small   sloughing   polypi. 

In  the  late  stages,  when  the  cervix  is  destroyed  and  an 
u 


Cancer  of  the  cervix  (A.  E.  G.). 


2IO 


DISEASES   OF   WOMEN. 


ulcerating  cancerous  mass  replaces  it,  there  is  no  difficulty 
in   rccoLjni/.ing  its  nature. 

A  fatal  termination  is  induced  in  a  variety  of  ways : 

1.  The  ulceration  may  open  the  uterine  artery  and  cause 

fatal  hemorrhage. 

2.  Repeated  bleedings  lead  to  exhaustion  and  death. 

Ovary  iiifillratid  with  cancer. 


Fallopian  tube. 

Ureter. 

Round  ligament. 

Occluded  ureter. 
Cancer-mass. 


Vesical  orifice  of 
ureter. 


Fig.  73. — Cancer  of  ihc  cervix  uteri  iniplicaliiit;  the  ureter  and  bladder. 


3.  Implication  of  the  bladder  and  ureter  (Fig.  y^  causes 

cystitis,  septic  pyelitis,  and  uraemia. 

4.  Septic  changes  in  the   uterus  extend  to  the   Fallopian 

tubes  and  cause  pyosalpinx. 

5.  Peritonitis  may  be  due  to  rupture  of  a  pus-containing 

Fallopian  tube. 


DISEASES   OF   THE    UTERUS.  211 

6.  Intestinal  obstruction  may  follow  adhesion  of  small  or 

large  intestine  to  the  uterus,  or  direct  extension  of  the 
growth  to  the  rectum. 

7.  Hydroperitoneum  and  hydrothorax  may  be  due  to  sec- 

ondary nodules  of  cani:er  on  the  peritoneum  and 
pleura. 
Treat  ill  cut. — When  the  disease  is  detected  early,  before  it 
has  had  time  to  overrun  the  cervix  and  implicate  the  vagina 
or  infiltrate  the  connective  tissue  surrounding  the  supra- 
vaginal section  of  the  cervix,  high  amputation  of  the  cervix 
may  be  carried  out  with  good  prospect  of  prolonging  life. 
When  there  is  reason  to  believe  that  the  disease  has  ex- 
tended beyond  the  internal  os,  then  the  whole  uterus  should 
be  extirpated  by  the  vaginal  method.  Many  operators 
maintain  that  in  carcinoma,  even  when  limited  to  the  vag- 
inal portion  of  the  cervix,  the  best  treatment  is  vaginal 
hysterectomy,  and  it  is  highly  probable  that  this  view 
will  prevail. 

Cancer  of  the  Cervix  and  Pregnancy. — It  is  quite 
certain  that  a  woman  with  cancer  of  the  cervix  may  con- 
ceive, and  it  is  by  no  means  easy  in  the  early  stages  to  de- 
tect the  complication,  because  in  many  cases  cancer  of  the 
cervix  leads  to  enlargement  of  the  uterus. 

In  a  large  proportion  of  cases,  when  pregnancy  and  can- 
cer of  the  cervix  coexist,  abortion  occurs  ;  nevertheless,  the 
pregnancy  sometimes  goes  to  term,  and  it  becomes  neces- 
sary to  determine  whether  the  patient  should  be  submitted 
to  Caesarean  section  or  hysterectomy.  The  course  most 
usually  followed  is  Cesarean  section.  In  the  majority  of 
cases  in  which  this  complication  is  encountered  the  disease 
is  too  extensive  to  permit  of  radical  surgical  measures  for 
its  relief  When  the  existence  of  cancer  is  detected  in  the 
mid-period  of  gestation,  it  is  advisable  to  terminate  the  preg- 
nancy, and  in  a  few  days  deal  with  the  cancer,  if  it  should  be 
in  such  a  stage  as  to  afford  hope  of  a  successful  issue. 

Cancer  of  the  uterus  and  an  ovarian  cyst  may  coexist. 


212  DISEASES   OF   WOMEN. 

This  combination  is  rare,  but  the  presence  of  the  cancer,  if 
extensive,  would  be  a  bar  to  ovariotomy. 

Cancer  of  the  cervix  and  uterine  myomata  sometimes 
coexist.  In  the  early  stages  such  a  combination  could  be 
effectively  dealt  with  by  panhysterectomy.  In  the  later 
stages  of  the  disease  the  capsule  of  the  myoma  is  involved 
by  ulceration,  and  the  hard  tissue  of  the  myoma  is  infiltrated, 
softened,  and  destro)'ed  with  remarkable  rapidity. 

Cancer  of  the  Body  of  the  Uterus. — This  is  much 
less  frequent  than  cancer  of  the  cervix.  It  arises  in  the 
tubular  glands  which  exist  in  the  mucous  membrane  lining 
the  cavity  of  the  uterus.  Little  accurate  knowledge  is  forth- 
coming in  regard  to  its  early  stages.  The  cancer  remains 
for  a  long  period  restricted  to  the  body  of  the  uterus,  and 
eventually  creeps  into  one  or  both  Fallopian  tubes :  it  rarely 
invades  the  cervical  canal,  and  then  only  in  the  late  stages. 
It  is  apt  to  perforate  the  uterine  wall  and  infect  the  perito- 
neum. 

Symptoms. — Cancer  of  the  body  of  the  uterus  is  rare  be- 
fore the  forty-fifth  year;  it  is  most  frequent  at  or  subsequent 
to  the  menopause  ;  most  cases  occur  between  the  fiftieth  and 
seventieth  years  ;  the  patients  are  nearly  always  nulliparje. 

The  signs  that  usually  attract  attention  are  the  occurrence 
of  fitful  hemorrhages  after  the  menopause,  followed  by  pro- 
fuse and  offensive  discharges,  which  are  often  blood-stained. 
On  examination  the  cervi.x  feels  normal  and  may  appear  so 
when  examined  with  the  help  of  a  speculum,  but  the  uterus 
often  feels  larger  than  natural. 

The  disease  is  very  apt  to  be  mistaken  for  some  variety 
of  endometritis :  on  the  other  hand,  endometritis  is  fre- 
quently regarded  as  cancer  of  the  body  of  the  uterus. 

The  diaofiosis  is  usually  made  by  dilating  the  cervical 
canal  and  removing  a  fragment  of  tissue  from  the  uterine 
cavity  and  examining  it  microscopically  (Fig.  74). 

Treatment. — When  the  cervical  canal  is  dilated  for  diag- 
nostic purposes,  the  mucous  membrane  should  be  scraped, 


DISEASES   OF   THE    UTERUS. 


213 


for  if  the  disease  should  prove  to  be  simply  some  form  of 
endometritis,  the  curetting  will  be  beneficial ;  even  if  it 
should  be  cancer,  this  manner  of  treatment  is  often  useful 
in  checking  bleeding  for  a  time. 

In  some  instances  it  will  be  clear,  on  examining  the  uterus 
after  dilating  the  cervical  canal,  that  the  disease  is  cancer, 
and  if  the  operator  is  satisfied  from  the  mobility  of  the  ute- 
rus that  there  is  no  implication  of  surrounding  tissues,  he 


Fig.  74. — Microscopic  charactc 


if  cancer  of  the  body  of  the  uterus  (from  a  scraping). 


will  do  w^ell,  if  he  has  the  consent  of  the  patient,  to  remove 
the  uterus. 

Vaginal  hysterectomy  for  cancer  of  the  body  of  the  ute- 
rus is  followed  by  excellent  results,  immediate  and  remote. 

Occasionally  cancer  of  the  body  of  the  uterus  causes 
such  enlargement  of  the  organ  that  abdominal  h}'sterec- 
toniy  is  necessary. 

Retention-cysts. — When  from  any  cause  the  cervical 
canal  is  permanently  obstructed,  the  secretions  of  the  glands 
and,  at  certain  periods,  menstrual  blood  are  retained  and 
dilate  the  cavity  of  the  uterus.  Retention-cysts  of  this  kind 
receive  names  according  to  the  nature  of  the  retained  fluid. 


214  DISEASES   OF   WOMEN. 

HcEViatomctrc. — This  form  is  due  to  retained  blood  :  its 
causes  and  treatment  are  discussed  in  Chapter  VI. 

Jlydronictra. — This  results  from  cicatricial  occlusion  of 
the  cervical  canal,  usually  the  result  of  injury  during  par- 
turition, and  is  particularly  apt  to  occur  in  one  horn  of  a 
double  uterus.  The  secretion  from  the  glands  accumulates 
and  distends  the  cavity  of  the  uterus,  and  the  distended 
organ  mimics  a  myoma  or  a  pregnant  uterus. 

Pyovictra. — This  is  occasionally  a  sequel  to  hydrometra 
and  h<x'mot(Miietra ;  putrefactive  organisms  gain  access  to 
the  highly  albuminous  contents  of  the  uterus  and  establish 
suppuration.  Pyometra  is  not  an  uncommon  complication 
of  cancer  of  the  cervix  uteri. 

It  may  be  taken  as  an  axiom  that  if  occlusion  occur  dur- 
ing menstrual  life,  haeinatometra  results  ;  after  the  meno- 
pause, hydrometra  or  pyometra.  If  the  occlusion  is  due 
to  cancer,  then  pyometra  is  the  ccjnscquencc.  These  con- 
ditions are  more  frequent  in  two-horned  uteri  than  in  those 
of  normal  form. 

Diagnosis  and  Treatment. — So  far  as  hn^matometra  is 
concerned  the  chief  points  in  diagnosis  and  treatment  were 
described  in  Chapter  VI.,  and  the  details  therein  mentioned 
will  serve  to  guide  the  student  in  the  recognition  of  p}'ome- 
tra,  which  is  a  somewhat;  infrequent  condition,  except  when 
it  complicates  carcinoma  of  the  cer\ix.  An  uncomplicated 
case  of  p)'ometra  is  easily  treated  by  freel}'  opening  up  the 
cervical  canal,  evacuation  of  the  pus,  and  the  employment 
of  efficient  irrigation. 

Bchinococcus  Colonies. — These  are  rareh-  met  with 
in  the  uterus  ;  they  occur  as  cysts  situated  immediateh'  be- 
neath the  peritoneal  investment  of  the  uterus. 


CHAPTER    XXIV. 

DISEASES    OF    THE    FALLOPIAN    TUBES. 

MALFORMATIONS,    DISPLACEMENT,    IN- 
FLAMMATION,   AND  TUMORS. 

Malformations. — These  are  of  no  practical  importance. 
The  abnormahty  which  is  most  Hkely  to  attract  attention  is 
the  presence  of  one  or  even  two  accessory  ostia  in  the  am- 
pulla. An  accessory  ostium  is  surrounded  by  a  tuft  of 
fimbriae.  Deficient  development  or  total  absence  of  a  tube 
is  usually,  but  not  always,  associated  with  defective  develop- 
ment of  the  corresponding  half  of  the  uterus. 

Hernia  of  the  Tube  (Salpingocele). — This  is  rare,  but 
hernia  of  the  ovary  and  tube  is  by  no  means  uncommon. 

Inflammation  of  the  Fallopian  Tubes  (Salpingitis). 
— This  is  nearly  always  secondary  to  septic  infection  of  the 
genital  tract. 

The  chief  causes  are  septic  endometritis  following  labor, 
abortion,  or  gangrene  of  a  uterine  polypus  ;  gonorrhoea^ 
tuberculosis,  and  cancer  of  the  uterus. 

The  changes  produced  by  septic  endometritis  and  gonor- 
rhoea are  almost  identical,  and  the  effects  produced  may 
be  studied  under  four  headings :  i.  The  acute  stage;  2.  The 
occlusion  of  the  tubal  ostium;  3.  Pyosalpinx ;  4.  Hydro- 
salpinx. 

The  Acute  Stage. — When  the  infection  extends  from 
the  mucous  membrane  of  the  uterus  to  that  of  the  tubes, 
the  tubal  tissues  become  soft,  succulent,  swollen,  and  friable. 
The  surface  of  the  mucous  membrane  is  covered  with  glu- 
tinous pus,  which  exudes  from  the  abdominal  ostium  when 

215 


2l6 


DISEASES   OF   IVOMEN. 


tlic  tube  is  squeezed.  When  this  infective  material  escapes 
from  tile  tubes  into  the  pelvic  section  of  the  ccelom  it  sets 
up  pelvic  peritonitis,  which  is  not  infrequently  rapidly  fatal ; 
when  it  super\'enes  on  delivery  or  abortion  it  is  commonly 
termed  "puerperal  perit(jnitis."  The  occurrence  of  infective 
peritonitis  in  this  way  has  been  demonstrated  on  many  oc- 
casions by  carefully  conducted  autopsies.  Acute  j^onor- 
rhceal  peritonitis  sometimes  occurs  in  the  same  way,  though 
it  is  far  less  frequently  fatal  than  that  which  follows  septic 
endometritis. 

The  direct  channels  established  by  the  Fallopian  tubes 
between  the  cavity  of  the  uterus  and  the  ccelom  (general 
peritoneal  cavity)  facilitate  peritoneal  infection.  But  its  fre- 
quency is  diminished  in  a  very  important  manner  by  occlu- 
sion of  the  abdominal  ostia  of  the  tubes — a  pathological 
sequence  of  great  value  in  so  far  as  the  saving  of  life  is 
concerned. 

Occlusion  of  the  Ostium. — When  inflammation  ex- 
tends from  the  tubal  mucous  membrane  to  the  peritoneum 

adjacent  to  the  ostium,  it 
leads  to  the  formation  of 
adhesions  in  consequence 
of  the  organization  of  the 
exudation,  which  leads  to 
the  matting  together  of 
the  tubal  fimbria,-;  this 
also  glues  them  to  the 
ovar)'  and  posterior  la)'er 
of  the  broad  ligament,  and 
occasionally  to  a  coil  of 
intestine.  This  mechanic- 
ally seals  the  ostium. 

There  is  another  in- 
teresting and  probably 
slower  way  in  which  these  ostia  become  occluded.  The 
fimbriae  are  lu.xuriant    protrusions  of  tubal   nuicnus   mcm- 


FiG.  75. — Ovary,  mesosalpinx,  and  outer  half 
of  the  Fallopian  tube.  The  ostium  is  com- 
pletely occluded. 


DISEASES   OF   THE  FALLOPIAN   TUBES.  21/ 

brane  beyond  the  ostium.  When  the  tubes  are  inflamed 
the  muscular  and  serous  coats  lengthen  and  bulge  over  the 
fimbria.'  until  each  ostium  appears  as  a  rounded  smooth  ori- 
fice instead  of  being  fringed  ;  gradually  the  rounded  margins 
contract,  cohere,  and  occlude  the  opening.  In  the  early 
stages,  if  the  rounded  end  of  the  occluded  tube  be  slit  up, 
the  fimbricX'  will  be  found  crowded  inside  the  tube.  This 
mode  of  occlusion  is  termed  "  salpingitic  closure  of  the 
ostium  "  (Fig.  75). 

This  sealing  up  of  the  ostium  is  a  remarkable  and  con- 
servative process  in  so  far  as  the  life  of  the  individual  is 
concerned.  The  occluded  tube  now  becomes  the  seat  of 
important  changes  whereby  it  is  converted  into  a  pyosal- 
pinx,  a  hydrosalpinx,  or  undergoes  sclerosis. 

Pyosalpinx. — This  may  be  defined  as  a  Fallopian  tube 
with  an  occluded  abdominal  ostium,  the  cavity  of  the  tube 
being  distended  with  pus. 

In  the  early  stages  a  pyosalpinx  may  not  exceed  the  fin- 
ger in  thickness,  but  in  a  fair  proportion  of  cases  the  tube 
becomes  distended  and  its  walls  thicken  in  some  parts  and 
thin  in  other,  until  it  assumes  the  shape  and  attains  the 
size  of  a  ripe  banana.  Exceptionally  a  pyosalpinx  forms 
a  swelling  large  enough  to  rise  above  the  brim  of  the 
pelvis. 

A  pyosalpinx  adheres  to  adjacent  structures,  such  as  the 
ovary,  mesometrium,  bowel,  and  especially  the  rectum. 
Sometimes  the  wall  of  the  sac  bursts  and  the  pus  is  dis- 
charged into  the  ccelom  (general  peritoneal  cavity)  and  sets 
up  fatal  peritonitis.  More  frequently  a  pyosalpinx  opens 
into  the  rectum  and  the  pus  escapes  by  the  anus.  This  is 
one  method  of  spontaneous  cure. 

In  severe  cases  of  salpingitis,  as  has  already  been  men- 
tioned, the  ovary  is  almost  always  implicated,  and  while  the 
tube  is  undergoing  conversion  into  a  pyosalpinx  an  abscess 
forms  in  the  ovary.  The  sacculated  pus-containing  tube  and 
the  abscess  in  the  ovaiy  may  remain   distinct,  but  ver}'  fre- 


2l8 


DISEASES   OE  WOMEN. 


qucntly  the  two  fuse  together  and  form  what  is  known  as  a 
tul)o-ovarian  abscess  (I'^ij^.  76). 

Hydrosalpinx. —  This  may  be  defined  as  a  Fallopian 
tube  distended  with  serous  fiuiti  in  consequence  of  inflam- 
matory occlusion  of  its  ccelomic  ostium. 

Salpingitis  does  not  always  lead  to  occlusion  of  the  ab- 
dominal ostia  of  the  tubes.  A  mild  attack  may  conveniently 
be  described  as  "  catarrh  of  the  tubes,"  and,  like  a  nasal  or 
gastric  catarrh,  subsides  and  leaves  no  trace.     When  the  in- 


Tiibe 


Ovarian  ligament 


Ovary 


Fig.  76. — 'I'libo-ovarian   abscess. 

flammation  has  been  sufficiently  severe  to  seal  the  ostium 
the  tube  is  permanently  damaged.  Such  a  tube  becomes 
passively  distended  with  fluid  and  converted  into  a  legume- 
shaped  cyst. 

A  hydrosalpinx  sometimes  possesses  walls  so  thin  that 
it  is  translucent  and  devoid  of  adhesions.  In  other  cases 
the  wall  is  universally  adherent.  Some,  if  not  most,  exam- 
ples of  hydrosalpinx  are  secondary  to  jn'osalpinx,  the  puru- 
lent contents  of  wiiich  have  become  sterile. 


DISEASES   OF  THE  FALLOPIAN   TUBES.  2ig 

Hydrosalpingcs  vary  greatly  in  size  :  the  specimen  repre- 
sented in  Fig.  yy  is  of  average  proportions.  When  a  hy- 
drosalpinx exceeds  that  size,  it  will  often  form  a  swelling 
appreciable  above  the  brim  of  the  true  pelvis  ;  very  large 
specimens  arc  often  erroneously  termed  tubo-ovarian  cysts 
and  ovarian  hydroceles. 

Litcnfiittiiig  Hydrosalpinx. — It  has  been  stated  on  clinical 
evidence  that  the  fluid  in  a  hydrosalpinx  may  escape  through 
the  uterus,  the  blockade  of  the  uterine  end  of  the  Fallopian 
tube  being  raised.  Such  a  condition  is  termed  "  hydrops 
tubae  profluens,"  the  escape   of  the   fluid  taking  place  at 


Fig.  77. — Hydros.ilpinx. 

irregular  intervals.  Profuse  discharges  of  pus  and  fluid 
occur  in  connection  with  pyo-  and  hydrosalpinx,  accompa- 
nied by  a  diminution  in  the  size  of  the  tumor,  due  to  the 
formation  of  a  fistula  between  the  cyst  and  the  rectum  or 
the  vagina. 

It  is  a  fact  of  some  interest  that  the  uterine  end  of  the 
Fallopian  tube  is  rarely  obliterated  in  salpingitis.  Of  course 
the  tumidity  of  the  mucous  membrane  would  be  sufficient 
in  most  cases  to  obstruct  the  passage  of  fluid  from  the  tube 
into  the  uterus. 

Haematosalpinx. — This  term  is  applied  to  a  distended 


220  DISEASES   OF   WOMEN. 

non-gravid  Fallopian  tube  with  an  occluded  abdominal 
ostium.     The  cavity  contains  blood  or  blood-stained  fluid. 

Ha^matosalpinx  is  a  rare  condition  :  many  specimens  for- 
merly catalogued  under  this  term  prove  on  careful  exam- 
ination to  be  gravid  tubes.  This  matter  is  discussed  in  the 
section  devoted  to  Tubal  Pregnancy. 

Sclerosis  of  the  Tubes.— Every  Fallopian  tube  affected 
with  chronic  salpingitis  is  not  converted  into  a  pyosalpinx 
or  a  hydrosalpinx :  it  may  become  changed  into  a  hard, 
fibrous  body  traversed  by  an  irregular  canal. 

In  the  early  stages  of  salpingitis  the  tubal  walls  are  in- 
filtrated with  inflammatory  exudation :  gradually  this  exu- 
dation organizes  into  fibrous  tissue  and  the  true  tubal  struc- 
tures atrophy.  It  is  a  ver>'  slow  process,  and  probably  six 
years  is  required  for  the  conversion.  The  process  is  identi- 
cal with  that  which  leads  to  stricture  of  the  male  urethra. 
It  is  not  unusual  to  find  a  hydrosalpinx  on  one  side  of  the 
uterus  and  a  sclerosed  Fallopian  tube  on  the  other. 

Sclerosed  tubes  are  sometimes  sources  of  danger,  as 
small  abscesses  form  in  them,  perforate  the  wall  of  the  tube, 
and  lead  to  adhesion  of  small  intestine,  and  cause  fatal  in- 
testinal obstruction. 

Tubercular  Salpingitis. — Most  examples  of  this  dis- 
ease are  undoubtedly  secondary  to  tuberculosis  of  the  en- 
dometrium. The  naked-eye  features  of  a  tubercular  tube 
are  often  very  characteristic,  but  it  is  sometimes  impossible 
to  distinguish  it  from  a  pyosalpinx.  In  man)'  instances  the 
abdominal  ostium  is  occluded  and  the  tube  tightly  stuffed 
with  caseous  material  (Fig.  78).  On  removing  this  material 
the  mucous  membrane  presents  the  usual  velvet-like  ap- 
pearance characteristic  of  the  walls  of  a  chronic  abscess. 

In  many  patients  tubercles  are  found  in  other  parts  of 
the  body,  so  that  it  is  difficult  to  decide  which  is  the  pri- 
mary seat  of  the  disease.  The  bacilli  are  often  difficult  of 
detection  ;  however,  when  tubes  are  found  distended  with 
caseous   pus    and    deposits   containing  tubercle-bacilli  are 


DISEASES   OF   TIIK   FALLOPIAN   TUBES. 


221 


found  in  other  organs,  it  may  be  used  as  evidence  that  the 
disease  in  the  tubes  is  hkewise  tubercular.  The  only  abso- 
kite  test  of  tubercular  salpingitis  is  the  detection  of  the 
tubercle-bacilli  in  the  contents  or  the  tissues  of  the  Fallo- 
pian tube. 

It  is  an  important  clinical  fact  that  many  cases  of  tubercu- 
lar peritonitis  in  infants,  girls,  and  young  women  are  due  to 


Fig.  78. — Tubercular  salpingitis,  from  an  infant. 

infection  from  tubercular  tubes  in  consequence  of  the  ostia 
remaining  unoccluded.  Exceptionally  infection  of  the  peri- 
toneum has  resulted  from  perforation  of  a  tubercular  tube. 
It  is  also  possible  that  the  tubes  may  sometimes  be  infected 
secondarily  to  tubercular  peritonitis,  due  to  tuberculosis  of 
the  intestine. 

Non-inflattittiatory  Stenosis  of  the  Tubal  Ostium. 
— There  is  a  curious  and   somewhat   rare  variety  of  tubal 


222  DISEASES   OF   WOMEN. 

distention  which  is  sometimes,  though  erroneously,  de- 
scribed as  pyosalpinx  ;  it  is  not  caused  by  septic  changes 
in  tlie  uterus  or  by  gonorrhoea.  The  patients  arc  usually 
virgins,  or,  if  married,  they  are  sterile. 

In  well-marked  specimens  the  tubes  become  converted 
into  huge  banana-like  or  legume-shaped  cysts,  which  not 
only  appear  above  the  pelvic  brim,  but  may  reach  as  high 
as  the  navel.  The  abdominal  ostium  is  usually  completely 
occluded,  but  traces  of  the  fimbriai  may  be  observed  even 
in  extreme  cases.  The  contents  of  these  dilated  tubes 
are  viscid  like  old  honey,  and  are  occasionally  of  the  con- 
sistence of  putty.  In  some  specimens  the  mucous  mem- 
brane resembles  wet  chamois  leather.  This  rare  variety  of 
tubal  disease  seldom  causes  inconvenience  until  the  enlarge- 
ment of  the  tubes  produces  obvious  swelling  of  the  lower 
part  of  the  belly.  The  change  probably  depends  on  non- 
inflammatory (possibly  congenital)  stenosis  of  the  abdom- 
inal ostia  of  the  Fallopian  tubes. 

Tumors  of  the  Fallopian  Tube. — These  are  exces- 
sively rare,  and  belong  to  four  genera:  Myoma,  adenoma, 
sarcoma,  and  carcinoma. 

Myoma. — Tumors  composed  of  unstriped  muscle  tis- 
sue growing  from  the  Fallopian  tube  are  among  the  great- 
est rarities  of  oncology :  this  is  extraordinary,  considering 
the  extreme  frequency  of  myomata  in  the  uterus.  Even 
when  growing  from  the  tube  they  rarely  attain  such  sizes 
as  to  be  clinically  important. 

Sarcoma. — At  present  this  is  so  rare  a  tumor  of  the 
tube  that  it  may  be  regarded  as  merely  of  pathological  in- 
terest. 

Adenoma. — Tumors  composed  of  glandular  tissue  have 
on  several  occasions  been  observed  growing  from  the  tubal 
mucous  membrane.  An  adenoma  of  the  Fallopian  tube 
may  assume  the  dendritic  form  of  a  large  papilloma,  or  con- 
sist of  a  mass  of  cyst-like  swellings  and  resemble  a  bunch 
of  grapes.     The  stroma  of  the  tumor  consists  of  delicate 


DISEASES   OE  THE  FALLOPIAN   TUBES.  223 

connective  tissue  in  which  glandular  acini,  lined  with  a 
single  layer  of  colunniar  epithelium,  are  imbedded.  Some 
of  the  cysts  present  in  these  tumors  contain  intracystic  pro- 
cesses. A  curious  feature  connected  with  these  tumors  is 
the  presence  of  free  fluid  in  the  belly — hydroperitoneum. 
This  is  due  to  the  secretion  from  the  adenoma  escaping 
through  the  abdominal  ostium  of  the  tube  and  irritating 
the  peritoneum.  Although  the  peritoneal  fluid  may  be 
evacuated,  it  accumulates  as  long  as  the  adenoma  is  allowed 
to  remain.  Removal  of  the  adenoma  at  once  and  perma- 
nently arrests  the  effusion. 

Carcinoma. — This  disease  as  a  primary  affection  is  ex- 
cessively rare.  The  tubes  are  occasionally  implicated  by 
extension  of  cancer  from  the  uterus. 


CHAPTER    XXV. 

DISEASES  OF  THE   EALLOPIAN  TUBES   (Continued). 

DIAGNOSIS   AND    TREATMENT   OF    SALPIN- 

GITIS. 

Acute  Salpingitis. — The  leading  signs  of  this  affection 
are  not  dependent  on  the  tubes,  but  become  manifest  when 
the  infection  extends  from  the  tubes  to  the  pelvic  perito- 
neum. When  this  disease  is  secondary  to  septic  endome- 
tritis the  signs  often  come  on  with  great  suddenness.  The 
discharges  from  the  uterus  arc  offensive ;  the  patient  may 
have  a  temperature  of  ioo°  F.  Suddenly  she  is  seized  with 
a  rigor;  the  temperature  rises  to  103°  or  104°;  the  belly 
quickly  swells ;  and  in  twenty-four  hours  there  is  clear  evi- 
dence of  infective  peritonitis.  In  some  of  these  cases  death 
follows  in  a  few  days ;  in  others  the  patients  slowly  recover. 
When  these  signs  supervene  on  delivery  or  abortion,  the 
condition  is  often  called  puerperal  peritonitis. 

Similar  attacks  are  sometimes  seen  after  operations  upon 
the  uterus,  and  may  complicate  a  gangrenous  intra-utcrinc 
myoma  (polypus). 

As  a  rule,  slow  accession  of  symptoms  indicates  gradual 
extension  of  infection  from  mucous  and  muscular  to  serous 
tissue.  Sudden  onset  of  the  severe  signs  means  actual  leak- 
age from  the  tube  into  the  coelom  (general  peritoneal  cav- 
ity). In  some  cases  acute  infection  of  the  peritoneum  is  in- 
dicated by  profound  collapse.  The  above  signs  may  be 
interpreted  thus  :  slow  extension  leads  to  chronic  changes  ; 
leakage,  as  a  rule,  leads  to  general  infective  peritonitis,  and 
not  infrequently  to  death. 
224 


DISEASES   OF  THE   FALLOPIAN   TUBES.  225 

It  should  also  be  borne  in  mind  that  sudden  infection  of 
the  pelvic  peritoneum  during  labor  may  arise  from  the 
bursting  of  a  pyosalpinx,  or  a  suppurating  ovarian  cyst  of 
small  size. 

Acute  pelvic  peritonitis  sufficiently  severe  to  imperil  life 
occasionally  occurs  in  the  early  stage  of  gonorrhoea  before 
the  coelomic  (abdominal)  ostia  become  scaled. 

Treatment. — Acute  salpingitis  demands  absolute  rest  in 
bed  and  the  routine  use  of  mild  vaginal  injections.  The 
bowels  should  be  kept  regular  with  mild  saline  purgatives. 
When  the  pelvic  pain  is  very  great  warm  fomentations 
should  be  applied  to  the  hypogastrium,  and  morphia  or 
opium  may  be  judiciously  prescribed. 

When  the  signs  indicate  extensive  fouling  of  the  peri- 
toneum and  the  patient's  life  is  imperilled,  the  surgeon  may 
have  to  consider  the  advisability  of  performing  cceliotomy. 
In  all  cases  in  discussing  treatment  the  surgeon  is  bound  to 
remember  that  his  diagnosis  is  not  infallible,  and,  though 
the  signs  may  indicate  leakage  from  an  infected  tube,  it  may 
be  due  to  a  rupture  of  an  ovarian  or  a  perityphlitic  abscess. 
In  such  cases  cceliotomy  is  the  only  hopeful  course. 

Chronic  Salpingitis. — This  is  a  very  common  disease, 
and  one  that  not  infrequently  imperils  life ;  even  in  cases 
when  life  is  not  endangered,  the  pain  and  inconvenience 
these  women  suffer  are  often  such  as  to  render  them  chronic 
invalids. 

The  chief  points  are  these :  The  patient  is  usually  be- 
tween twenty  and  thirty-five  years  of  age,  and  furnishes  a 
history  of  difficult  labor  or  abortion,  followed  by  a  pro- 
tracted illness,  since  which  she  has  been  sterile  and  suf- 
fered from  excessive,  prolonged,  and  often  painful  menstru- 
ation. Defecation  and  sexual  congress  are  sources  of  pain  ; 
some  complain  also  of  a  vaginal  discharge.  Married  women, 
and  occasionally  single  women,  furnish  details  of  such  a 
kind  as  lead  us  to  believe  that  an  attack  of  gonorrhoea 
marked  the  beginning  of  the  trouble. 

15 


2  26  DISEASES   OE   WOMEN. 

The  symptoms,  briefly  summarized,  are  menorrhagia, 
pain,  and  sterility. 

Tubercular  salpingitis  has  wider  age-limits,  as  it  occurs 
in  chiklreii  from  eighteen  months  onward  (Fig.  79).  In 
girls  after  puberty  this  variety  of  salpingitis  is  often  accom- 
panied by  amenorriuea. 

On  examining  the  abdomen  an  irregular  tender  swelling 
may  be  sometimes  detected  in  one  or  both  flanks ;  more 
frequently  there  is  an  indefinite  swelling,  and  in  some,  on 
palpation,  a  sense  of  resistance  can  be  made  out,  but  in 
very  many  cases  no  swelling  can  be  detected. 

On  internal  examination  there  will  be  found  Ijing  on 
each  side  of  or  behind  the   uterus  an  elongated  swelling, 


Fig.  79. — Tubercular  salpingitis,  from  a  baby. 


which  usually  gives  rise  to  great  pain  when  pressed  by  the 
examining  finger.  Not  infrequently  the  uterus  is  acutely 
retroflexed,  and  then  the  uterine  fundus  with  the  enlarged 
tubes  and  ovaries  forms  a  rounded  ridge  running  trans- 
versely across  the  pelvic  floor. 

As  a  rule,  a  moderately  distended  tube  can  onl}'  be  felt 
through  the  vagina  or  by  the  bimanual  method. 

Tactile  judgment  is  a  very  important  factor  in  the  diag- 
nosis of  pehic  swellings.  To  estimate  the  size,  consistence, 
fixity,  or  mobility  of  a  tumor  l}ing  in  close  relationship  with 
the  uterus  requires  e.xperience. 

In  a  general  way,  it  may  be  stated  that  it  is  impossible  to 


DISEASES   OF   THE  FALLOPIAN   TUBES.  22/ 

accurately  diagnose  between  the  various  forms  of  tubal  and 
the  followinij  forms  of  ovarian  disease : 

1.  Tubercular  abscess  of  ovary; 

2.  Apoplexy  of  the  ovary  ; 

3.  Small  ovarian  cysts,  tumors,  or  dermoids  ; 

4.  Small  parovarian  cysts  ; 

5.  Gravid  tubes  previous  to  rupture  or  abortion. 

The  following  conditions  are  very  liable  to  be  mistaken 
for  tubal  disease : 

Retroflexion  of  the  uterus  ; 

Pelvic  cellulitis  ; 

Fecal  accumulation  in  the  rectum  ; 

A  kidney  in  the  hollow  of  the  sacrum  ; 

A  small  uterine  myoma  ; 

Cancer  of  the  sigmoid  flexure  of  the  colon  ; 

Abscess,  due  to  inflammation  of  the  vermiform  appen- 
dix burrowing  into  the  mesometrium  ; 

Tumors  of  the  sacrum  or  innominate  bone  ; 

Tumors  of  the  mesometrium,  including  echinococcus 
colonies. 
When  a  Fallopian  tube  is  so  distended  as  to  render  it 
capable  of  being  felt  above  the  pelvic  brim  it  is  liable  to  be, 
and  often  is,  mistaken  for  an  ovarian  cyst.  On  the  other 
hand,  when  ovarian  and  parovarian  cysts  are  not  large 
enough  to  be  felt  above  the  pelvic  brim  they  closely  simu- 
late pelvic  cellulitis  or  distended  tubes. 

Trcatinoit. — When  the  tubal  mucous  membrane  has  be- 
come seriously  damaged  and  the  tubes  fixed  by  adhesions 
to  surrounding  structures,  then  drugs  are  of  little  avail. 
When  such  persons  are  able  to  lead  a  life  of  ease  they  often 
become  chronic  invalids  and  try  Continental  health  resorts, 
where  they  visit  the  springs  and  indulge  in  baths,  especially 
the  mud-baths  of  Bohemia.  In  poorer  patients  such  treat- 
ment is  out  of  the  question,  and  in  order  to  lead  a  useful 
life,  as  well  as  to  escape  from  pain,  they  willingly  submit  to 
surcfical  measures. 


228  DISEASES   OE   WOMEN. 

The  orciiiiary  rules  of  surgery  suggest  that  wlicii  the 
physical  signs  iiulicate  that  the  Fallopian  tubes  are  occluded 
and  distended  with  pus  or  other  fluid,  producing  pain  and 
inconvenience,  so  as  to  cause  the  patient  to  lead  the  life  of 
a  chronic  invalid,  it  is  justifiable  to  remove  them. 

Removal  of  the  Fallopian  tubes  and  ovaries  (oophorec- 
tomy) is  justifiable  and  the  only  radical  means  of  treatment 
in  the  following  conditions  :  Pyosalj^inx  and  tubo-ovarian 
abscess ;  hydrosalpinx ;  ovarian  abscess ;  tubercular  sal- 
pingitis. 

In  tubercular  salpingitis  oophorectomy  should  only  be 
undertaken  when  there  is  no  evidence  of  tubercle  in  other 
organs,  such  as  lungs,  bladder,  or  kidneys.  The  method 
of  performing  oophorectomy  is  described  in  the  section 
devoted  to  the  description  of  operations. 


CHAPTER   XXVI. 
DISEASES   OF   THE    FALLOPIAN    TUBES    (Continued). 

TUBAL  PREGNANCY. 

In  order  to  reach  the  uterine  cavity  an  ovum  must  traverse 
the  Fallopian  tube.  When  an  oosperm  (fertilized  ovum)  is 
retained  in  the  tube  it  develops  and  gives  rise  to  the  condi- 
tion known  as  "  tubal  pregnancy." 

Concerning  the  cause  or  causes  of  tubal  pregnancy  noth- 
ing is  known,  and  this  uncertainty  will  continue  until  reliable 
evidence  is  forthcoming  in  regard  to  the  situation  in  the 
genital  passages  where  ovum  and  spermatozoon  normally 
meet.  It  is  reasonable  to  believe  that  fertilization  normally 
happens  in  the  uterus,  but  when  it  occurs  in  the  tube  it  is 
accidental  and  tubal  pregnancy  is  the  consequence.  It  is 
probable  that  when  an'  ovum  is  converted  into  an  oosperm 
the  latter  immediately  engrafts  itself  on  the  adjacent  mucous 
membrane,  whether  it  be  tubal  or  uterine. 

Tubal  pregnancy  may  happen  as  a  first  pregnancy  in 
women  who  have  been  married  eight,  ten,  or  even  twenty 
years.  A  Fallopian  tube  may  become  gravid  in  the  newly 
married  or  in  the  mother  of  a  large  family.  Both  tubes 
may,  in  very  exceptional  instances,  be  gravid  concurrently, 
or  one  tube  may  become  pregnant  years  after  its  fellow. 
Very  rarely  two  oosperms  are  retained  in  the  same  Fallo- 
pian tube — twill  tubal  pregnancy.  Tubal  may  complicate 
uterine  pregnancy. 

An  analysis  of  a  large  number  of  cases  establishes  the 
fact  that  tubal  pregnancy  is  very  apt  to  occur  in  women 
who  have  been  sterile  many  years,  and  has  given  color  to 

229 


230  DISEASES   OF   WOMEN. 

the  suggestion  that  chronic  saljjin^itis  ami  loss  of  tulial 
epithelium  may  predispose  to  this  accident.  A  careful  sc- 
ries of  investigations  on  an  abundant  supply  of  material 
teaches  us  that  a  healthy  Fallopian  tithe  is  rnore  likely  to 
become  gravid  than  one  wJiieh  has  been  injhnnetl. 

The  events  which  follow  the  retention  of  an  oosperm  in 
a  Fallopian  tube  vary  according  to  its  position,  thus  : 

Retention  in  the  ampulla  and  isthmus  is  called  tubal 
gestation. 

Retention  in  the  portion  traversing  the  uterine  wall  is 
known  as  tubo-uterine  gestation.  This  variety  requires 
separate  consideration. 

The  stages  of  tubal  pregnancy  will  be  described  in  sec- 
tions, as  follows  : 

Changes  in  the  tube ; 

The  tubal  mole ; 

Tubal  abortion ; 

Tubal  rupture ; 

The  decidua  and  placenta. 
The  Changes  in  the  Tube. — During  the  first  month 
or  six  weeks  following  the  lodgement  of  an  oosperm,  the 
tubal  tissues  are  swollen  and  turgid ;  occasionally  at  the 
site  where  the  villi  are  implanted  the  tubal  wall  becomes 
very  thin.  In  many  cases,  especially  when  the  oosperm  is 
lodged  in  the  ampulla  of  the  tube,  the  abdominal  ostium 
gradually  closes  by  a  process  very  analogous  to  that  de- 
scribed as  resulting  from  salpingitis.  Occlusion  of  the  ab- 
dominal ostium  is  a  slow  process  and  requires  probably 
eight  weeks  for  its  completion  (Fig.  80).  When  the  oosperm 
is  retained  in  the  isthmus  or  in  the  uterine  section  of  the 
tube  the  abdominal  ostium  is  rarely  affected.  In  a  fair  pro- 
portion of  cases  the  ostium  dilates  instead  of  contracting. 
There  is  as  yet  no  good  explanation  forthcoming  in  re- 
gard to  these  two  opposite  conditions,  but  they  exercise  an 
important  influence  on  the  subsequent  course  of  the  preg- 
nancy.    Microscopic  investigation  of  the  uterine  end  of  the 


DISEASES   OE   THE   EALLOPIAN    TUBES. 


231 


tube  serves  to  show  that  it  is  not  obstructed  when  the  tube 
is  gravid. 

The  Tubal  Mole. — The  changes  which  occur  in  the 
oosperm  are  the  same  whether  it  be  lodged  in  a  Fallopian 
tube  or  in  the  uterine  cavity  :  in  each  situation  it  is  liable  to 
become  converted  into  what  is  known  as  a  "  mole."  Such 
a  body  is  an  early  embryo  and  its  membranes  into  which 
blood  has  been  extravasated.  Tubal  moles  vary  greatly  in 
size :  some  have  been  detected  with  a  diameter  of  i  cm. ; 


Fig.  So. — Gravid  Fallopian  tube  with  completely  occluded  ostium. 


others  measure  5  or  even  8  cm.  Small  tubal  moles  are 
globular,  but  after  they  attain  a  diameter  of  3  cm.  they  as- 
sume an  ovoid  shape.  The  amniotic  cavity  usually  occu- 
pies an  eccentric  position  ;  occasionally  the  embryo  is  de- 
tected within  it  (Fig.  81).  More  often  it  escapes,  or  is  de- 
stroyed by  the  original  catastrophe  which  formed  the  mole. 
When  no  embryo,  amniotic  cavity,  or  chorionic  villi  can  be 
detected  by  the  naked  eye,  a  microscopic  examination  of 
sections  will  lead  to  the  detection  of  chorionic  villi.  They 
are  very  characteristic  structures  (see  Fig.   52,  page  166), 


232 


j>/s/:asi:.s  oj-    II  omj-:\. 


and  as  certain  evidence  of  tubal  pregnancy  as  tlic  embryo 
itself. 

It  is  an  interesting  fact  that  the  blood  in  a  tubal  mole  lies 
between  the  chorion  and  the  amnion  in  a  temporary'  space 
known  as  the  subchorionic  chamber.  This  blood  is  derived 
from  the  circulation  of  the  embryo,  and  a  large  proportion 
of  the  red  corpuscles  are  nucleated. 

Tubal  moles  only  arise  in  the  first  two  months  following 
fertilization.  The  laminated  condition  of  the  clot  presented 
by  some  of  these  bodies  indicates  that  a  mole  is  sometimes 
formed  by  a  succession  of  hemorrhages. 


Fig.  8i. — Tubal  mole,  whole  and  in  section. 


Tubal  Abortion. — It  has  already  been  pointed  out  that 
the  lodgement  of  an  oosperm  in  the  outer  third  of  the  tube 
usually  leads  to  occlusion  of  the  abdominal  ostium  by  the 
end  of  the  eighth  week.  So  long  as  this  orifice  remains 
open  the  oosperm  is  in  constant  jeopardy  of  being  extruded 
through  it  into  the  ccelom  (peritoneal  cavity),  especially 
when  lodged  in  the  ampulla  of  the  tube ;  the  nearer  it  is 
situated  to  the  ostium  the  greater  the  risk  of  its  ejection 
from  the  tube.  To  this  accident  the  term  tidml  alwvtion  is 
ajipiicd,  for  it  is  parallel  to  tluxse  earh'  abortions  occurring 
in  uterine  gestation  before  the  end  of  the  second  month ; 


DISEASES   OF   THE   FALLOPIAN   TUBES. 


233 


and  it  further  resembles  them  in  the  fact  that  the  oosperm 
is  nearly  always  converted  into  a  mole. 

In  tubal  abortion  the  mole  is  occasionally  discharc^cd 
through  the  ostium  into  the  coelom  (peritoneal  cavity)  with 
a  copious  hemorrhage,  accompanied  with  the  usual  signs  of 
internal  bleeding,  and  death  may  occur  early  from  the 
anaemia  thus  induced  or  from  shock.     In  such  instances 


I''iG.  82. — Fallopian  tube  immediately  alter  "  complete  tubal  abortion, 
drawing  represents  the  "  mole." 


The  lower 


the  mole,  being  very  small,  may  escape  recognition  when 
the  clot  is  examined  either  at  operation  or  post-Dwrtcui. 

The  amount  of  blood  discharged  into  the  coelom  under 
these  conditions  sometimes  amounts  to  two,  three,  or  even 
four  litres.  When  the  mole  is  extruded  from  the  tube 
through  the  unclosed  abdominal  ostium  it  is  described  as 
"  complete  tubal  abortion  "  (Fig.  82) ;  very  frequently  the 


234  D /SEAS IIS   OF   If'OMEAf. 

mole  is  retained  in  the  tube ;  it  is  then  referred  to  as  "  in- 
complete tubal  abortion."  The  retention  of  the  mole  leads 
to  recurrent  hemorrhat^'e.  The  loss  of  blood  in  both  varie- 
ties of  tubal  pregnancy  is  often  so  ^reat  as  to  imperil  life. 

Tubal  abortion  is  of  ^reat  interest,  as  the  bleeding  which 
accompanies  it  was  formerly  erroneously  ascribed  to  metror- 
rhagia, reflux  of  menstrual  blood  from  the  uterus,  or  hem- 
orrhage from  the  tubal  mucous  membrane. 

Rupture  of  the  Gestation  Sac. — It  is  an  undeniable 
fact  that  every  gravid  tube  left  to  itself  either  aborts  or 
bursts.  When  from  any  cause  the  pregnancy  is  disturbed 
before  the  abdominal  ostium  is  occluded,  the  probability  is 
in  favor  of  abortion,  but  a  gravid  tube  often  ruptures  in 
spite  of  a  patent  ostium.  When  the  pregnancy  advances 
until  the  ostium  is  closed,  then  the  tube  bursts  at  some 
period  between  the  sixth  and  tenth  week  following  impreg- 
nation ;  this  accident  is  rarel)''  deferred  till  the  twelfth  week. 
This  is  called  primary  rupture,  and  may  be  intraperitoneal 
or  extraperitoneal.  The  determining  causes  of  the  rupture 
are  of  various  kinds,  such  as  jumping  from  a  train,  chair,  or 
carriage;  defecation;  sexual  congress;  examination  of  the 
uterus,  etc.  Occasionally  no  such  influence  is  demon- 
strable. 

Primary  Intraperitoneal  Rupture. — In  this  variety 
the  rupture  is  so  situated  that  the  blood  escapes  into  the 
ccelom  and  inundates  the  recto-vaginal  fossa.  The  embryo 
or  mole  may  escape  through  the  rent  or  be  detained  in  the 
tube. 

The  blood  effused  may  amount  to  two  litres  or  even 
more.  Extravasations  of  this  kind  were  formerly  called 
pelvic  ha^matoceles.  This  term  could,  with  advantage  to 
the  student,  suffer  obliteration. 

The  dangers  of  primary  intraperitoneal  rupture  of  a 
gravid  tube  are  rapid  death  from  hemorrhage  or  death 
from  repeated  hemorrhages.  Women  occasionally  survive 
a  limited  hemorrhage,  and  the  effused  blood  slowly  absorbs. 


DISEASES   OF  THE   FALLOPIAN   TUBES.  235 

When  the  bleeding  is  not  excessive  the  blood  collects  in 
the  rectovaL,nnal  fossa,  and  floats  up  the  coils  of  intestines, 
and  these,  with  the  omentum,  (gradually  form  a  covering  to 
the  fossa  by  adhering  together,  thus  isolating  the  blood  in 
the  pelvis  from  the  general  peritoneal  cavity.  Taylor  has 
shown  that  the  effused  blood  in  these  cases  sometimes 
coagulates    in   layers  and   forms  a  spurious  cyst. 

Primary  Bxtraperitoneal  Rupture. — In  a  fair  pro- 
portion of  cases  the  tube  bursts  in  that  portion  of  its  cir- 
cumference lying  between  the  folds  of  the  mesosalpinx. 
When  this  happens  the  mole  and  a  varying  amount  of 
blood  are  forced  between  the  layers  of  the  mesometrium. 
As  a  rule,  the  bleeding  is  arrested  before  it  assumes 
dangerous  proportions  in  consequence  of  the  resistance 
which  occurs  when  the  mesometric  tissues  become  dis- 
tended. This  is  fortunate,  for  the  blood  and  mole  are 
entombed  in  the  mesometrium,  and  rarely  cause  subse- 
quent trouble. 

Rupture  may  take  place,  the  embryo  with  its  membranes 
remain  uninjured,  and  the  pregnancy  continue;  for,  no 
longer  confined  within  the  narrow  limits  of  the  tube,  it  be- 
gins to  avail  itself  of  the  additional  space  thus  offered,  and 
burrows,  as  it  grows,  between  the  layers  of  the  mesomet- 
riufn. 

According  to  the  manner  in  which  this  mode  of  rupture 
is  sometimes  described,  it  mis^ht  be  imagined  that  the  tube 
splits  and  the  products  of  gestation  are  suddenly  discharged 
from  the  tube  into  the  mesometrium.  This  is  not  the  case, 
or  the  pregnancy  would  in  every  instance  come  to  an  end 
from  the  dissociation  of  the  foetal  from  the  maternal  struc- 
tures. A  careful  study  of  the  morbid  anatomy  of  the  acci- 
dent indicates  that  the  slow  and  gradual  distention  of  the 
tube  causes  it  to  thin  and  gradually  yield  in  that  part  of  its 
circumference  uncovered  by  peritoneum,  until  an  opening 
forms,  accompanied  by  sudden  hemorrhage,  which  produces 
collapse,  the  profundity  and  duration  of  which  depend  upon 


236  DISEASES   OF   WOMEN. 

the  amount  of  blood  effused.  Tliis  artificial  opening  gradu- 
ally extends,  while  the  growing  embryo  and  placenta  make 
their  way  into,  and  by  degrees  occupy,  the  new  area  of  con- 
nective tissue  opened  up,  unless  the  life  of  the  embryo  is 
terminated  by  renewed  hemorrhage. 

When  gestation  continues  in  this  way  it  is  spoken  of  as 
"  mesometric  pregnancy,"  because  the  sac  is  formed  in  jiart 
by  the  expanded  Fallopian  tube  and  the  layers  of  perito- 
neum forming  the  mesometrium. 

The  Placenta  and  Decidua. — In  tubal  gestation  the 
placenta  is  liable  to  many  vicissitudes  which  influence  very 
seriously  the  life  of  the  foetus,  and  are  such  grave  sources 
of  danger  to  the  mother  that  they  demand  great  considera- 
tion from  the  surgeon. 

A  uterine  placenta  consists  of  foetal  and  maternal  ele- 
ments, but  a  tubal  placenta  possesses  foetal  elements  only 
(chorionic  villi),  for  in  a  tubal  pregnancy  a  decidua  forms  in 
the  uterus,  not  in  the  tube ;  further,  the  tubal  mucous  mem- 
brane takes  veiy  little  share  in  the  formation  of  the  placenta. 
It  is  the  primitive  character  of  the  tubal  placenta  which 
helps  to  make  the  embryo's  life  so  precarious. 

The  Decidua. — In  all  varieties  of  tubal  pregnancy  a 
decidua  forms  in  the  uterine  cavity ;  it  is  rarely  retained 
until  term;  when  it  is,  the  membrane  is  thrown  off  dui^ing 
the  false  labor  characteristic  of  that  period.  More  fre- 
quently the  decidua  is  discharged  in  pieces  during  the  early 
period  of  labor  or  is  expelled  whole  with  signs  of  miscar- 
riage. Decidual  vary  in  thickness  from  6  to  8  nmn.  They 
may  be  described  as  bags  resembling  in  outline  an  isosceles 
triangle  (Fig.  83).  The  base  corresponds  to  the  fundus  of 
the  uterus,  and  the  apex  to  the  internal  opening  of  the  cer- 
vical canal.  At  each  angle  of  the  triangle  there  is  an  open- 
ing. Those  at  the  basal  angles  correspond  to  the  Fallo- 
pian tubes,  and  the  apical  orifice  to  the  cervical  canal.  The 
outer  aspect  is  shaggy,  and  the  inner  surface  is  dotted  with 
the  orifices  of  uterine  glands.     The  angle  corresponding  to 


DISEASES   OE   THE  FALLOPIAN  TUBES. 


237 


the  internal  orifice  of  the  cervical  canal  is  often  represented 
by  a  large  opening. 

The  histology  of  a  decidua  is  best  studied  in  sections  cut 
parallel  with  the  surface.  In  this  way  the  epithelium  lining 
the  ducts  of  the  uterine  glands  is  well  shown.  The  spaces 
not  lined  with  epithelium  are  blood-vessels. 


Fig.  83.— Uterus  with  the  decidua  in  situ  (from  a  case  of  tubal  pregnancy). 

It  is  useful,  for  clinical  purposes,  to  be  familiar  with  the 
microscopic  characters  of  deciduse,  because  it  happens  that 
an  early  uterine  abortion  often  simulates  primary  rupture  of 
a  gravid  tube,  and  vice  versa.  On  examining  shreds  which 
have  escaped  from  the  vagina  one  is  able  to  decide  by 
means  of  the  microscope  whether  they  are  fragments  of 
decidua  or  chorionic  villi  from  a  uterine  conception. 

Displacement  of  the  Placenta. — Up  to  the  date  of 


238  DISEASES   OE   WOMEN. 

primary  rupture  the  formation  of  the  placenta  has  been 
procecdinf^  in  relation  with  the  mucous  membrane  of  the 
tube,  but  after  this  occurrence,  if  the  disturbance  is  not 
severe  enoufjh  to  terminate  the  pregnancy,  the  course  of 
events  is  modified  in  a  remarkable  manner,  and  the  ultimate 
result  is  lar<;ely  determined  by  the  relative  position  of  the 
fcetus  and  placenta. 

When  the  embryo  is  situated  above  the  placenta,  the 
latter  gradually  grows  and  insinuates  itself  between  the 
layers  of  the  mesomctrium  (broad  ligament)  until  it  comes 
to  rest  upon  the  floor  of  the  pelvis.  Should  the  embryo 
he  below  the  placenta,  the  foetus  will  ultimately  come  to 
rest  on  the  pelvic  floor,  and  the  placenta  will  be  pushed 
upward  by  the  growing  foetus. 

This  gradual  displacement  leads  to  disastrous  changes, 
such  as  repeated  hemorrhages  into  the  placenta,  which  im- 
pair its  functions  and  lead  to  arrest  of  development  and 
death  of  the  fcetus.  A  tubal  foetus,  even  when  it  survives 
to  term,  is  always  an  unsatisfactory  individual.  When  res- 
cued by  the  surgeon  these  foetuses  rarely  live  more  than  a 
few  weeks  or  months.  Many  are  ill-formed  and  present 
hydrocephalus,  club-foot,  ectopia  of  the  viscera,  and  the  like. 

Should  the  fcetus  die  early,  the  placenta  gradually  atro- 
phies, and  in  cases  of  lithopaedion  there  is  no  trace  of  it. 

Secondary  Rupture  of  the  Sac. — The  constant  ten- 
sion to  which  the  gestation  sac  is  exposed  may,  if  increased 
by  a  sudden  hemorrhage,  lead  to  rupture  and  death.  This 
is  known  as  "  secondar}^  intraperitoneal  rupture."  Occa- 
sionally the  gestation  continues  to  term  ;  then  symptoms 
of  labor  set  in,  and,  as  deliveiy  by  the  natural  channels  is 
impossible,  the  sac  may  burst  into  the  ccelom.  Escaping 
this,  the  fcetus  dies,  and,  remaining  quiescent,  becomes 
mummified  or  is  transformed  into  a  lithopa^dion.  Later  the 
soft  parts  may  become  adipocere,  or  decompose.  When  the 
fcL-tal  tissues  putrefy,  then  the  pus  bursts  through  the  blad- 
der, rectum,  vagina,  or  through  the  abdominal  wall,  and 


DISEASES   OF   THE   FALLOPIAN   TUBES.  239 

fragments  of  foetal  tissue  and  bones  arc  discharged  from 
time  to  time.  This  is  known  as  "  secondary  extraperitoneal 
rupture." 

A  lithop.'udion — that  is,  a  fcetus  whose  tissues  are  impreg- 
nated with  lime  salts  (calcified) — may  remain  quiescent  for 
many  months  or  even  fifty  years ;  indeed,  may  never  cause 
subsequent  trouble ;  but  it  is  always  a  potential  source  of 
danger,  for  if  pathogenic  micro-organisms  gain  access  to  it, 
suppuration  is  the  inevitable  consequence. 

Thus,  of  the  two  varieties  of  secondary  rupture,  the  intra- 
peritoneal may  occur  at  any  period  from  the  date  of  the 
primary  rupture  to  term  ;  whereas  the  extraperitoneal  variety 
may  not  take  place  for  months  or  even  years. 

The  cases  of  secondary  intraperitoneal  rupture  where  the 
foetus  is  found  free  among  the  intestines  were  formerly  re- 
garded as  examples  of  fertilized  ova  which  had  become 
engrafted  on  the  peritoneum  and  developed  into  foetuses. 
Happily,  this  error  no  longer  prevails,  and  we  now  know 
that  all  forms  of  extra-uterine  pregnaticy  pass  their  primary 
stages  in  the  Fallopian  tubes. 

Tubo-uterine  Gestation. — When  an  oosperm  lodges 
in  that  section  of  the  tube  which  traverses  the  uterine  wall 
it  is  termed  tubo-uterine  gestation.  It  is  very  rare,  many 
specimens  described  under  this  name  being  examples  of 
pregnancy  in  the  rudimentary  horn  of  a  unicorn  uterus. 

This  variety  runs  a  somewhat  different  course  to  the 
common  variety  of  tubal  pregnancy.  For  example,  pri- 
mary rupture  may  be  delayed  to  the  sixteenth  week.  The 
sac  may  rupture  in  two  directions.  It  may  burst  into  the 
coelom,  and  is  often  rapidly  fatal ;  or  it  may  rupture  into 
the  uterine  cavity  and  be  discharged  like  a  uterine  embryo. 
A  tubo-uterine  gestation-sac  never  ruptures  into  the  meso- 
metrium  (broad  ligament). 

Although  in  many  examples  of  tubo-uterine  gestation 
primary  rupture  may  be  longer  delayed  than  in  purely 
tubal  gestation,  nevertheless  the  sac  sometimes  bursts  very 


240  DISEASES   OF   WOMEN. 

early ;  in  such  cases  death  usually  takes  place  within  a  few 
hours  from  hemorrhaj^e. 

An  examination  of  the  clinical  details  of  cases  of  un- 
doubted tubo-uterine  <^estation  indicates  that  intraperitoneal 
rupture  of  the  sac  is  more  rapidly  fatal  in  the  tubo-uterine 
than  in  the  purely  tubal  form.  This  is  due  to  the  greater 
amount  of  hemorrhage,  because  not  only  are  the  walls  of 
the  gestation  sac  thicker,  but  the  rent  often  extends  to,  and 
involves,  the  wall  of  the  uterus. 


CHAPTER   XXVII. 

DISEASES    OF   THE   FALLOPIAN   TUBES    (Continued). 

DIAGNOSIS    AND     TREATMENT    OF     TUBAL 
PREGNANCY. 

Diagnosis. — The  signs  of  tubal  pregnancy  vary  accord- 
ing to  the  stage  of  the  gestation ;  they  will  therefore  be 
dealt  with  in  sections,  thus  : 

1.  Before  primary  rupture  or  abortion  ; 

2.  At  the  time  of  primary  rupture  or  abortion ; 

3.  From  the  date  of  primary  rupture  to  term ; 

4.  At  and  after  term. 

1.  Before  Rupture  or  Abortion. — Since  the  pathology 
of  the  early  stages  of  tubal  pregnancy  has  been  carefully 
investigated  and  a  clear  distinction  recognized  between  a 
gravid  tube  and  a  haematosalpinx,  many  cases  have  been 
recorded  in  which  a  correct  diagnosis  was  made  before  the 
operation  was  undertaken.  This  is  veiy  gratifying,  and  it  is 
a  matter  of  great  importance  for  the  patient,  as  it  spares 
her  the  awful  peril  which  attends   rupture  of  the  tube. 

The  patient  usually  gives  a  definite  history  of  a  missed 
menstrual  period  after  having  been  previously  regular ;  fol- 
lowing on  this  event  she  begins  to  experience  pelvic  pain 
which  induces  her  to  seek  advice.  On  examination  an  en- 
larged Fallopian  tube  is  detected.  When  there  is  no  his- 
tory of  old  tubal  disease,  or  any  fact  in  the  history  of  the 
patient  suggesting  septic  endometritis  or  gonorrhoea,  then 
presumption  favors  a  gravid  tube. 

2.  At  the  Time  of  Primary  Rupture  or  Abortion. — 
The  tube  bursts  or  abortion  occurs  at  some  period  before 

16  241 


242  D I  SEAS  I. S    01-    WOMEN. 

the  twelfth  week  :  the  effect  upon  tlic  patient  depends  upon 
the  seat  of  rupture.  When  it  takes  pkice  between  the  hiyers 
of  the  mesometrium  (broad  Hgament),  the  symptoms  will, 
as  a  rule,  be  less  severe  than  when  the  tube  bursts  into  the 
ccelom,  because  the  pressure  exercised  by  the  blood  ex- 
travasated  into  the  tissues  of  the  mesometrium  tends  to 
check  hemorrhage ;  whereas  the  ccelom  will  hold  all  the 
blood  the  patient  possesses,  and  yet  produce  no  haemostatic 
effect  in  the  form  of  pressure. 

The  svniptoms  of  intraperitoneal  rupture  are  those  charac- 
teristic of  internal  hemorrhage.  The  patient  complains  of 
a  sudden  feeling  "  as  if  something  had  given  way ;  "  this  is 
followed  by  general  pallor  and  faintness  ;  the  voice  is  re- 
duced to  a  mere  whisper :  sighing  respiration  ;  depression 
of  temperature  ;  rapid  and  feeble  pulse;  usually  vomiting ; 
and  in  some  cases  death  ensues  in  a  few  hours.  Should 
the  patient  recover  from  the  shock,  she  will  sometimes  state 
that  she  suspected  herself  to  be  pregnant. 

The  symptoms  of  rupture  are  often  accompanied  by  hem- 
orrhage from  the  vagina,  and  shreds  of  decidua  will  be 
passed,  so  that  the  case  resembles  in  many  points,  and  is 
occasionally  mistaken  for,  early  uterine  abortion.  Error  in 
such  circumstances  may  be  avoided  by  examining  the 
shreds  discharged  from  the  uterus  :  if  they  are  found  to  be 
chorionic  villi,  the  pregnancy  is  clearly  uterine. 

The  rapidity  with  which  the  rupture  of  a  gravid  tube  will 
sometimes  destroy  life  has  caused  more  than  one  writer  to 
describe  this  accident  as  "  one  of  the  most  dreadful  calami- 
ties to  which  women  can  be  subjected  ;  "  indeed,  it  may  be 
so  rapidly  fatal  that  many  cases  have  been  recorded  in 
which  death  has  been  attributed  to  poisoning  until  dissec- 
tion, instituted  in  many  instances  by  the  coroner,  has  re- 
vealed the  true  cause  of  death. 

In  extraperitoneal  rupture — that  is,  when  the  tube  bursts 
so  that  the  blood  is  cxtravasated  between  the  layers  of  the 
mesometrium — the  symptoms  resemble  intraperitoneal  rup- 


DISEASES   OE  THE   EAI.LOPIAN   TUBES.  243 

ture,  but,  as  a  rule,  are  not  so  severe  and  the  signs  of  shock 
pass  off  quicker.  On  examining  by  the  vagina  a  round,  ill- 
defined  swelling  will  be  detected  on  one  side  of  the  uterus; 
when  the  effused  blood  is  large  in  amount  the  uterus  will 
be  pushed  to  the  opposite  side.  When  the  bleeding  takes 
place  into  the  left  mesometrium  (broad  ligament),  it  will 
sometimes  extend  backward  under  the  peritoneum  and  in- 
vade the  connective  tissue  around  the  rectum,  so  that  when 
the  exploring  finger  is  introduced  into  the  rectum  a  semi- 
circle— sometimes  a  ring — of  swollen  tissue  will  be  felt  en- 
circling the  gut. 

The  escape  of  decidual  membrane  from  the  uterus  accom- 
panied by  blood  is  also  an  important  and  fairly  constant 
sign.  Occasionally  it  will  be  necessary  to  pass  a  sound  into 
the  uterus  ;  when  the  tube  is  gravid  the  cavity  of  this  organ 
will  be  found  slightly  enlarged  and  the  os  invariably  patu- 
lous. 

The  greatest  difficulty  in  these  cases  is  to  be  sure  that 
the  rupture  is  purely  extraperitoneal.  In  a  few  cases  the 
rupture  may  involve  the  peritoneal  as  well  as  the  meso- 
metric  segment  of  the  tube. 

Abortion  or  rupture  of  a  gravid  tube  is  often  simulated 
by  lesions  of  other  abdominal  organs  ;  for  example : 

Perforation  of  stomach  or  intestine  ; 

Sloughing  of  the  vermiform  appendix ; 

Bursting  of  a  pyosalpinx  ; 

Intestinal  obstruction  (acute) ; 

Renal  colic; 

Biliary  colic ; 

Axial  rotation  of  an  ovarian  tumor  (acute) ; 

Strangulated  hernia. 
3.  From  the  Date  of  Pregnancy  to  Term. — Not  infre- 
quently after  primary  extraperitoneal  rupture  the  symptoms 
of  shock  pass  oflf  and  the  embryo  continues  its  develop- 
ment ;  in  many  instances  the  patients  believe  themselves 
pregnant,  and  the  hemorrhages  from  which  they  suffer  and 


244  niSE/ISFS   OF   WOMEN. 

the  sij^ns  indicative  of  the  primary  rupture  may  merely 
cause  temporary  inconvenience.  As  the  embryo  increases 
in  size  the  abdomen  enlar^jes,  but  differs  at  first  from  ordi- 
nary uterine  gestation  in  that  the  enlargement  is  lateral 
instead  of  median. 

From  the  third  month  onward  the  leading  signs  of  tubal 
gestation  may  be  summarized  thus  : 

(a)  Amenorrhcea  is  occasionally  found  ;  frequentl}'  there 
is  hemorrhage  from  the  uterus  occurring  at  irregular  inter- 
vals, accompanied  by  the  escape  of  decidual  membrane. 
This  last  is  a  valuable  diagnostic  sign.  It  is  even  more 
valuable  if  the  patient  has  missed  one  or  two  periods. 

(b)  There  may  or  may  not  be  milk  in  the  breasts.  Its 
presence  is  a  valuable  indication.  From  its  absence  nothing 
can  be  inferred. 

(c)  The  uterus  is  slightly  enlarged ;  the  os  is  usually 
soft,  as  in  normal  pregnancy,  and  patulous. 

(d)  A  large  and  gradually  increasing  swelling  to  one  side 
and  behind  the  uterus.  Occasionally  the  foetal  heart  can  be 
heard,  and  in  advanced  cases  the  outlines  of  the  foetus  may 
be  distinguished. 

(e)  When  a  woman  in  whom  the  existence  of  tubal  ges- 
tation is  suspected  is  suddenly  seized  with  collapse  and  all 
the  signs  of  internal  bleeding,  it  is  indicative  of  rupture  of 
the  gestation  sac. 

(f)  Tubal  pregnancy  is  very  apt  to  occur  after  long 
intervals  of  sterility. 

4.  At  Term. — In  spite  of  all  the  risks  that  beset  the  life 
of  an  extra-uterine  child  and  that  of  its  mother,  the  preg- 
nancy may  go  to  term.  Then  a  remarkable  series  of 
events  ensue : 

(a)  Paroxysmal  pains  come  on,  resembling  those  of  natural 
labor,  accompanied  by  a  discharge  of  blood  and  mucus,  and 
dilatation  of  the  "  os." 

(b)  This  unavailing  labor  may  last  for  hours  or  weeks. 

(c)  The  mammse  may  secrete  milk  for  several  weeks. 


DISEASES   OF   THE   FALLOPIAN   TUBES.  245 

These  signs  sometimes  pass  away,  and  as  the  amniotic 
jfluid  is  absorbed  the  abdominal  swelling  subsides.  Months 
or  years  later  suppuration  takes  place  in  the  sac,  and  foetal 
tissues  may  be  discharged  through  the  belly-wall,  rectum, 
vagina,  bladder,  etc.,  and  give  a  clue  to  the  character  of  the 
abscess. 

Various  conditions  may  complicate  the  diagnosis  of  tubal 
pregnancy ;  thus  : 

1.  Uterine  and  tubal  pregnancy  are  sometimes  concurrent. 

2.  Uterine  sometimes  follows  tubal  pregnancy. 

3.  Tubal  pregnancy  may  be  bilateral. 

4.  Tubal  pregnancy  may  be  repeated. 

5.  Tubal  pregnancy  and  ovarian  tumors  occasionally 
coexist. 

It  is  also  important  to  bear  in  mind  that  tubal  pregnancy 
may  be  simulated  by  a  variety  of  conditions : 

1.  Uterine  pregnancy ; 

2.  Pregnancy  in  a  bicorned  uterus  ; 

3.  Retroversion  of  the  gravid  uterus ; 

4.  Spurious  pregnancy ; 

5.  Ovarian  tumors  ; 

6.  Tumors  of  the  mesometrium ; 

7.  Uterine  myoma ; 

8.  Faeces  in  the  rectum. 

TREATMENT  OF  TUBAL  PREGNANCY. 

The  risks  and  difficulties  of  operations  for  tubal  preg- 
nancy depend  mainly  on  the  stage  at  which  they  are  required : 

1.  Before  Primary  Rupture  or  Abortion. — In  this 
stage  the  operation  required  is  practically  that  of  oophorec- 
tomy. 

2.  At  the  Time  of  Primary  Rupture  or  Abortion. — 
When  the  symptoms  of  hemorrhage  are  unmistakable  and 
the  patient's  life  in  grave  danger,  coeliotomy  should  be  per- 
formed without  delay,  unless  there  is  good  evidence  that 
the  rupture    is    extraperitoneal.     The  employment  of  this 


246  DISEASES   OE   WOMEN. 

method  is  in  strict  accordance  with  the  canon  of  surgery, 
vahd  in  other  regions  of  the  body — viz.  arrest  hemorrhage 
at  the  earhest  possible  moment. 

There  are  few  accidents  that  test  the  skill,  ner\e,  and  re- 
source of  a  surgeon  more  than  cteliotomy  for  a  suspected 
intraperitoneal  rupture  of  a  gravid  tube,  and  few  operations 
are  followed  by  such  brilliant  results. 

The  method  of  performing  the  operation  before  and  at 
the  time  of  primary  rupture  is  identical  with  oophorectomy. 

Occasionally  the  rent  in  the  tube  will  involve  the  fundus 
of  the  uterus,  especially  when  the  embryo  is  lodged  near 
the  uterus.     Such  rents  should  be  carefully  sutured. 

3.  Subsequent  to  Primary  Rupture. — The  majority 
of  cases  are  submitted  to  operation  at  periods  varying  from 
a  few  days  to  weeks,  or  even  months,  after  the  tube  lias 
ruptured.  (It  has  been  already  pointed  out  that  in  an  ex- 
ceedingly large  proportion  of  cases  the  tube  is  occupied  by 
a  mole.) 

When  the  tube  ruptures  the  hemorrhage  may  not  be  so 
profuse  as  to  induce  death,  and  the  woman,  recovering  from 
the  shock,  does  not  manifest  such  grave  symptoms  as  to 
demand  surgical  aid.  The  consequence  is,  that  the  patient 
remains  for  several  weeks  under  palliative  treatment  (unless 
a  renewal  of  bleeding  kills  her),  and  at  last  she  seeks  surgi- 
cal advice;  appreciation  of  the  true  nature  of  the  case  leads 
to  operation. 

In  such  cases,  when  the  abdomen  is  opened,  the  free  blood 
in  the  abdominal  cavity  is  easily  removed  by  irrigation  with 
warm  water.  The  damaged  tube  and  ovaiy  are  removed 
as  in  oophorectomy.  When  there  is  much  free  blood  care 
must  be  taken  that  no  clots  are  allowed  to  remain  in  the 
iliac  fossae.  When  the  blood  has  remained  in  the  coelom 
for  several  weeks  after  rupture  it  is  invariably  necessary  to 
drain. 

4.  Mesometric  Gestation. — When  a  Fallopian  tube 
bursts  and  a  mole  is  displaced  between  the  layers  of  the 


DISEASES   OF   THE   FALLOPIAN    TUBES.  247 

mesometrium,  operative  interference  is  rarely  necessary. 
Occasionally  repeated  hemorrhage  renders  it  imperative  to 
incise  tlic  abdominal  wall,  open  the  mesometrium,  and  turn 
out  the  clot,  and,  after  stitching  the  sac  to  the  edges  of  the 
wound,  allow  it  to  gradually  close. 

In  those  cases  where  the  embryo  survives  the  primary 
rupture  and  continues  to  grow,  an  operation  may  be  neces- 
sary at  any  moment  on  account  of  secondary  rupture. 
When  gestation  has  not  advanced  beyond  the  fourth  month, 
it  may  be  possible  to  remove  the  embryo,  tube,  ovary,  and 
adjacent  portion  of  the  mesometrium  with  the  placenta 
and  to  thoroughly  clear  away  all  clots.  When  it  has  ad- 
vanced beyond  the  fourth  month,  the  placenta  is  too  large 
to  be  treated  in  such  a  summary  manner.  Certainly  after 
the  fifth  month  operative  measures  for  tubal  gestation  re- 
quire consideration  under  two  headings : 

1 .  The  treatment  of  the  sac ; 

2.  The  treatment  of  the  placenta. 

1 .  The  Treatment  of  the  Sac. — The  gestation  sac  in 
the  last  stages  of  tubal  pregnancy  consists  of  the  remnants 
of  the  expanded  tube  and  the  mesometrium,  which  may  be 
thickened  in  some  parts  and  expanded  in  others.  To  the 
walls  of  the  sac  coils  of  intestine  and  omentum  usually 
adhere. 

Experience  has  decided  clearly  enough  that  the  safest 
plan  is  to  incise  the  sac,  remove  the  foetus,  and  stitch  the 
edges  of  the  sac  to  the  abdominal  wound,  precisely  as  in 
the  plan  recommended  after  enucleating  large  cysts  and 
tumors  from  between  the   layers   of  the  mesometrium, 

2.  The  Treatment  of  the  Placenta. — With  our  pres- 
ent experience  the  rules  for  the  treatment  of  the  placenta 
may  be  formulated  thus  : 

(i)  When  the  placenta  is  situated  abov^e  the  foetus  it  is 
good  practice  to  attempt  its  removal. 

(2)  In  some  instances  the  placenta  becomes  detached  in 
the  course  of  the  operation  and  leaves  no  choice. 


248  DISEASES   OE   WOMEN. 

(3)  When  the  placenta  is  below  the  fcetus  it  nia)-  be 
left. 

(4)  Should  the  placenta  be  left,  the  sac  closed,  and  symi)- 
toms  of  suppuration  occur,  then  the  wound  must  be  re- 
opened and  the  placenta  removed. 

(5)  If  the  foetus  dies  before  the  operation  is  attempted, 
the  placenta  can  be  removed  without  risk  of  hemorrhage. 

The  great  risk  of  violent  hemorrhage  renders  an  opera- 
tion for  tubal  pregnancy  with  a  quick  placenta,  between  the 
fifth  and  ninth  months  of  gestation,  the  most  dangerous  in 
the  whole  range  of  surgery ;  hence  it  cannot  be  urged  with 
too  much  force  that  when  it  is  fairly  evident  that  a  woman 
has  a  tubal  pregnancy  it  should  be  dealt  with  by  operation 
without  delay. 

After  Death  of  the  Foetus  at  or  near  Term. — Ope- 
rations after  the  death  of  the  fcetus  are  less  complicated 
than  when  it  is  alive  and  the  placental  circulation  in  full 
vigor.  Not  only  is  the  proceeding  from  the  operative  point 
of  view  simplified,  but  the  results,  in  so  far  as  the  mother  is 
concerned,  are  much  more  satisfactory. 

When  the  operation  is  undertaken  in  cases  where  the 
foetus  is  in  the  condition  of  lithopcxdion  the  procedure  is 
very  simple,  because  the  placenta  has  completely  disap- 
peared. When  the  foetus  is  converted  into  adipocere  the 
foetal  tissues  adhere  to  the  walls  of  the  sac  and  render  the 
process  of  remov^al  tedious. 

After  Decomposition  of  the  Foetus  and  Suppura- 
tion of  the  Sac. — After  death  and  decomposition  of  the 
f<jt;tus,  sinuses  form  by  which  pus,  accomj)anied  by  fragments 
of  foetal  tissue  and  bones,  finds  an  exit,  either  through  the 
rectum,  vagina,  bladder,  or  uterus,  or  at  some  spot  in  the  an- 
terior abdominal  wall  below  the  umbilicus.  The  treatment  in 
such  cases  is  simplicity  itself  The  sinuses  should  be  dilated 
and  all  fragments  removed  from  the  cavity  in  which  they 
lie.  When  this  is  thoroughly  done,  the  sinuses  will  rapidly 
granulate  and  close.     Partial  operations  are  useless  ;  if  only 


DISEASES   OF  THE   FALLOPIAN  TUBES.  249 

a  portion  of  a   bone   is   allowed   to  remain,  a  troublesome 
sinus  persists. 

The  difficulties  and  grave  dangers  which  surround  sur- 
gical intervention  in  the  late  stages  of  tubal  pregnancy 
make  it  clear,  that  the  interests  of  a  patient  are  best  served 
when  the  surgeon  removes  a  gravid  tube  as  soon  as  it  is 
clearly  recognized. 


CHAPTER    XXVIII. 

DISEASES    OF    THE    OVARIES. 

AGE-CHANGES;  MALFORMATIONS;  DIS- 
PLACEMENTS; THE  CORPUS  LUTEUM; 
INFLAMMATION. 

Age-changes. — The  variations  in  the  .shape  of  the 
ovary  from  infancy  to  old  age  are  very  striking.  At  birth 
the  ovary  is  an  elongated  body,  resembling  in  shape  a  min- 
iature but  somewhat  flattened  cucumber,  lying  parallel  with 
the  Fallopian  tube ;  not  infrequently  its  borders  are  crcnate, 
and  occasionally  it  is  traversed  by  a  longitudinal  furrow. 
The  infantile  form  of  the  ovary  gradually  changes,  and  at 
puberty  it  has  become  transformed  into  the  smooth,  olive- 
shaped  gland  indicative  of  the  mature  woman.  From  the 
accession  of  puberty  until  the  fort\'-fifth  )'car  the  general 
contour  of  the  ovary  remains  undisturbed,  but  the  smooth- 
ness of  its  surface  is  marred  by  scars,  the  effects  of  repeated 
lacerations  caused  by  the  rupture  of  ripe  follicles.  The 
actual  size  of  the  gland  varies  according  to  the  individual : 
on  an  a\'eragc  it  measures  in  length  4  cm.,  tran.sversely  2.5 
cm.,  and  is  about  1.2  cm.  thick.  Its  average  weight  is  6 
grammes.      Rarely  are  the  two  ovaries  equal  in  size. 

From  the  age  of  forty-five  onward  the  ovaries  diminish 
in  size.  This  alteration  is  accompanied  by  arrest  of  men- 
struation. As  the  gland  shrinks  its  surface  becomes  irregu- 
lar and  is  often  marked  by  deep  wrinkles.  At  the  same 
time  profound  alterations  are  in  progress  within  the  gland, 
for  the  ova  and  their  follicles  gradualh'  disaj)j)ear,  and  in 
advanced  life  nothing  is  left  but  a  corrugated  bod}'  consist- 

260 


DISEASES   OE  THE    0  VARIES.  25  I 

ing  of  fibrous  tissue  traversed  by  a  few  blood-vessels  with 
thickened  (sclerosed)  walls.  An  ovary  in  a  woman  of 
seventy  years  weii^hs  about  i  gramme — that  is,  one-sixth 
of  what  it  probably  weighed  at  the  age  of  twenty. 

The  periods  of  life  mentioned  above  for  the  supervention 
of  age-changes  are  very  arbitrary,  and  in  some  women  they 
occur  much  earlier  and  may  still  be  regarded  as  physiologi- 
cal. But  when  the  ovaries  are  small  and  puckered  early  in 
the  sexual  period  of  woman's  life  (thirtieth  year),  the  con- 
dition is  described  as  pathological  and  the  ovary  is  said  to 
be  atrophied.  It  is  very  difficult  to  estimate  from  a  naked- 
eye  examination  of  an  ovary  its  ova-forming  value.  Many 
women  with  small  ovaries  have  had  large  families,  whilst 
others  with  sexual  glands  of  twice  or  thrice  their  dimensions 
remain  sterile  in  spite  of  every  effort  to  become  mothers. 

Malformations. — The  ovaries  like  other  organs  are 
liable  to  irregularities   in  their  development. 

Congenital  absence  of  both  ovaries  is  rare,  and  is  asso- 
ciated with  defective  development  of  the  uterus.  Absence 
of  one  ovary  usually  accompanies  deficiency  of  the  corre- 
sponding half  of  the  uterus  and  the  Fallopian  tube  and  ab- 
sence or  misplacement  of  the  corresponding  kidney.  In 
the  malformed  condition  of  the  uterus  known  as  "  unicorn 
uterus  "  the  ovary  often  retains  its  infantile  (cucumber-like) 
shape. 

Supernumerary  or  accessory  ovaries  are  mentioned  by 
some  writers  as  of  common  occurrence.  A  careful  consid- 
eration of  the  evidence  makes  it  clear  that  small  pedun- 
culated bodies  near  the  ovary  are  very  frequent,  but  they 
are  not  accessory  ovaries.  Many  of  them  are  partially 
detached  tubes  of  the  parovarium,  stalked  corpora  fibrosa, 
or  small  myomata  of  the  ovarian  ligament. 

So  far  as  the  facts  at  present  stand,  a  supernumerary 
ovary,  so  separated  from  the  main  gland  as  to  form  a  distinct 
ovary,  has  yet  to  be  described  by  a  competent  observer. 

Displacements. — Under  this  heading  it  will  be  neces- 


-5- 


DISEASES   OF   WOMEN. 


saty  to  consider  three  conditions:  Undescended  Ovary; 
Hernia  of  the  ()\'ary  ;   Prolapse  of  the  Ovary. 

(a)  Undescended  Ovary. — In  tiie  embryo  the  ovaries, 
Hkc  the  testicles,  are  in  close  relation  with  the  kidneys : 
<^radually  they  migrate  to  the  pelvis,  and  at  birth  they  lie 
on  the  psoas  magnus  muscle  in  close  relation  with  the  in- 
ternal abdominal  ring  (Fig.  84).  Soon  after  birth  the  ovaries 
occupy  positions  in  the  true  pelvis  near  its  brim  until  dis- 
turbed by  accident  or  pregnancy. 

In  very  rare  instances  an  ovary  remains  in  the  neighbor- 
hood of  the  kidney  or  in  some  position  between  the  kidney 


/^ 


Fig.  84. — Pelvic  organs  of  a  foetus  at  birth. 


and  the  brim  of  the  true  pelvis.  In  such  a  case  it  retains 
the  infantile  shape.  In  a  certain  proportion  of  cases  of  un- 
descended testis  on  the  right  side  the  caecum  fails  to  de- 
scend to  its  normal  position  in  the  right  iliac  fossa.  Reten- 
tion of  the  right  owdsy  in  the  loin  is  associated  with  a 
similar  disposition  of  the  caicum. 

(b)  Hernia  of  the  Ovary. — An  ovar>'  may  occupy  a 
hernial  sac  either  alone  or  in  company  with  the  Fallopian 
tube,  omentum,  intestine,  etc. ;  most  frequently  it  occupies 


D/SEASKS    OF   TJIK    OVARIES. 


253 


a  sac  in  the  inguinal  region,  less  frequently  in  the  femoral. 
It  has  been  found  herniated  through  the  obturator  foramen. 

Following  the  method  adopted  with  other  varieties  of 
hernia,  when  the  ovary  alone  occupies  a  hernial  sac  it  may 
be  termed  an  oopJiorocclc  ;  when  accompanied  by  the  tube, 
a  salpingo-odpliorocclc  ;  hernia  of  the  tube  alone  would  be  a 
salpi)igocclc. 

Oophoroceles  may  occur  in  the  early  months  of  infancy, 
but   congenital    hernia    of  the    ovary   is    excessively  rare. 


Neck  of  sac. 

Cyst  in  ovary. 
Fallopian  tube. 
Parovarium. 
Tubal  JifnbricB, 

Sac. 


"*'>»T'^ 


Fig.  85. — Hernia  of  the  ovary  and  tube  into  the  canal  of  Nuck  (from  a  child  three 
months  old). 

Many  writers  on  hernia  refer  to  it  as  a  common  condition  ; 
hence  it  is  necessary  to  point  out  that  the  rounded,  movable 
bodies  so  frequent  in  the  inguinal  canals  of  female  infants 
are  in  most  cases  hydroceles  of  the  canal  of  Nuck.  As  a 
rule  they  disappear. 

Hernia  of  the  ovary  may  occur  at  any  age ;  it  has  been 
observed  as  early  as  the  third  month  (Fig.  85)  and  as  late 
as  the  seventy-third   year. 

A  strangulated  oophorocele  or  salpingocele  gives  rise  to 
signs  such  as  characterize  epiploceles  or  enteroceles.     The 


2  54  DISEASES    OJ-    HO  MEN. 

signs  of  stranj^ulation  sometimes  depend  on  axial  rotation 
(torsion)  of  the  lierniated  ovary  and  tube. 

The  fundus  of  the  uterus  as  well  as  the  ovary  and  tube 
lias  been  found  in  an  inguinal  sac,  and  several  cases  have 
been  reported  in  which  a  pregnant  uterus  with  its  append- 
ages has  occupied  a  sac  protruding  through  the  inguinal 
canal. 

In  all  cases  in  which  a  supposed  ovary  is  removed  from 
the  inguinal  region  its  nature  should  be  substantiated  by 
the  microscope ;  in  many  instances  bodies  excised  in  this 
way  have  on  microscopic  examination  turned  out  to  be 
testes,  and  the  supposed  women  pseudo-hermaphrodites 
(see  p.   57). 

Treatment. — Herniated  ovaries  and  tubes  require  removal 
when  they  are  a  source  of  pain  and  in  women  who  cannot 
wear  a  truss.  The  operation  has  been  almost  entirely  con- 
fined to  those  who  have  to  maintain  themselves  by  hard 
work.  The  operation  is  performed  as  for  inguinal  hernia: 
The  pedicle  is  secured  with  silk,  the  ovary  and  tube  cut 
away,  and  the  stump  returned  into  the  ccelom.  The  sac  is 
dissected  out  and  its  neck  secured  with  reliable  catgut. 
When  herniated  ovaries  or  tubes  become  strangulated  or 
undergo  axial  rotation  (torsion),  operation  is  the  only  choice, 
as  the  urgent  symptoms  are  rarely  likely  to  be  differentiated 
from  those  which  arise  from  strangulation  of  herniated  in- 
testine. 

(c)  Prolapse  of  the  Ovary. — At  puberty  the  ovaries 
lie  parallel  and  on  a  level  with  the  brim  of  the  true  pelvis. 
From  this  position  they  arc  liable  to  be  disturbed  by 
pregnancy ;  retroflexion  of  the  uterus  ;  enlargement. 

Pregnancy. — The  alteration  in  the  size  of  the  uterus  dur- 
ing pregnancy,  and  the  stretching  to  which  the  pelvic  peri- 
toneum. Fallopian  tubes,  and  ovarian  ligaments  are  sub- 
jected, cause  them,  especially  if  pregnancy  be  frequently 
repeated,  to  become  very  lax.  Under  these  conditions  one 
or  other  ovary,  instead  of  retaining  its  usual  position  at  the 


DISEASES   OE   TI/E    O VARIES.  255 

brim  of  the  true  pelvis,  may  drop  upon  or  near  the  floor  of 
the  recto-vaginal  pouch.  When  the  left  ovary  is  thus  dis- 
placed it  lies  between  the  upper  part  of  the  vagina  and  the 
rectum. 

An  ovary  thus  displaced  is  said  to  be  prolapsed,  and  not 
infrequently  is  a  source  of  much  pain  and  distress,  for  it 
becomes  pressed  upon  during  defecation,  and  patients  com- 
plain of  the  severe  pain  they  experience  during  sexual  con- 
gress (dyspareunia). 

Rctrojlcxion  of  the  Uterus. — In  this  misplacement  the 
ovaries  are  drawn  into  the  pelvis  and  sometimes  become 
adherent  to  its   floor. 

Enlarged  Ovary. — When  an  ovary  is  enlarged  from  the 
presence  of  a  tumor  of  moderate  dimensions  its  weight  will 
lead  to  stretching  of  the  ovarian  ligament,  and  it  will  fall 
with  the  associated  structures  into  the  recto-vaginal  pouch. 
A  small  parovarian  cyst  will  act  in  a  similar  way. 

Diagnosis. — On  vaginal  examination  a  small  rounded  or 
elongated  body  will  be  found  low  in  the  recto-vaginal  fossa, 
and  usually  on  the  left  side.  The  frequency  with  which 
prolapsed  ovaries  occupy  this  side  is  due  to  the  fact  that 
the  fossa  is  deeper  on  the  left  than  on  the  right  side.  On 
touching  the  ovary  the  patient  winces  and  complains  of 
pain.  These  painful  sensations  are  most  acute  when  the 
ovary  is  touched,  but  they  are  often  evoked  when  the  neck 
of  the  uterus  is  pressed,  because  the  ovary  is  then  squeezed 
between  the  uterus  and  the  rectum. 

Treatment. — When  prolapse  of  the  ovary  depends  on  ret- 
roflexion of  the  uterus  it  may  be  relieved  by  rectifying  the 
malposition  of  the  fundus  and  maintaining  it  in  the  normal 
position  by  a  pessary.  In  troublesome  cases  it  is  some- 
times necessary  to  perform  hysteropexy.  When  the  pro- 
lapse is  due  to  the  presence  of  a  cyst  or  tumor,  then  ovari- 
otomy is  the  most  appropriate  method  of  treatment. 

The  Corpus  I<uteum. — This  curious  body  is  liable  to 
the   following    secondary   changes :    It    may  be    converted 


256  Disj:.ts/-:s  0J--  women. 

into  a  cyst ;    it    may  become    a  corpus  fibrosum ;    it   may 
calcify. 

(a)  Cystic  Corpora  Luha. — The  centre  of  a  corjjus  luteum 
is  occupied  by  a  cavity  w  liich  in  tlie  early  stages  is  filled 
with  blood.  The  walls  of  such  cysts  arc  thick  and  of  a 
bright-yellow  color  when  fresh  ;  the  cavity  is  lined  with  a 
thin,  delicate  membrane  and  filled  with  albuminous  fluid. 

The  cysts  rarely  exceed  the  dimensions  of  a  ripe  cherry 
and  cause  no  inconvenience. 

(b)  Corpora  Fibrosa. — These  are  tough,  semi-opaque 
bodies,  and  are  due  to  fibrous  changes  in  the  tissue  proper 
of  a  corpus  luteum.  Many  contain  a  small  central  cavity, 
others  a  laminated  body.  Less  frequently  they  become 
calcified.  Sometimes  a  corpus  fibrosum  is  pedunculated, 
and  is  then  apt  to  be  regarded  as  a  supernumerary  ovary. 
Corpora  fibrosa  may  attain  the  dimensions  of  a  hen's  o.^^ 
(Patenko). 

Care  must  be  exercised  to  avoid  confounding  apoplexy 
of  the  ovary  with  hemorrhage  into  the  cavity  of  a  small 
ovarian  cyst  or  extravasation  secondary  to  axial  rotation 
of  an  enlarged  ovary. 

Ovarian  Concretions. — In  very  rare  instances  blood  effused 
into  enlarged  ovarian  follicles  may  undergo  colloid  changes 
and  form  dense  bean-sbaped  bodies. 

(c)  Calcified  Corpora  Lutea. — When  calcified  a  corpus 
luteum  may  be  irregular  in  shape  or  rounded ;  it  usually 
exhibits  a  bright-yellow  color,  and  consists  of  tough,  fibrous 
tissue  impregnated  with  calcareous  particles. 

These  bodies  are  usually  firmly  imbedded  in  the  ovarian 
stroma ;  the  concretion  may  be  nodulated  on  its  outer  sur- 
face like  a  mulberry  calculus,  and  lodged  in  a  cyst  in  the 
substance  of  the  ovary.  Two  calcified  corpora  lutea  may 
be  present  in  one  ovary :  they  must  not  be  confounded  with 
calcified  corpora  fibrosa. 

Apoplexy  of  the  Ovary. — The  rupture  of  a  mature 
ovarian  follicle  is  always  accompanied  by  a  trifling  amount 


DISEASES   OF   THE    OVARIES.  257 

of  l:)lccdin<^;  when  a  follicle  is  unusually  lar^^c  the  blood- 
clot  occupying  it  may  be  as  big  as  a  ripe  gooseberry.  Fol- 
licular hemorrhage  of  this  character  rarely  gives  rise  to  any 
serious  consequences. 

Occasionally  blood  is  extravasated  so  freely  into  a  follicle 
that  it  bursts  the  walls  and  invades  the  stroma,  converting 
the  organ  into  a  spurious  cyst,  the  walls  of  which  are  formed 
of  expanded  ovarian  tissue  and  the  cavity  filled  with  blood. 

For  such  conditions  the  term  "  apoplexy  of  the  ovary  " 
should  be  reserved.  It  may  be  defined  as  hcviorvJiage  into 
the  ovarian  stroma  through  ruptnre  of  a  follicle  (Doran). 
Cases  have  been  reported  in  which  the  ovary  has  been  en- 
larged from  this  cause  to  the  size  of  a  billiard-ball. 

Blood  extravasated  into  the  ovarian  stroma  undergoes 
the  same  change  as  when  it  escapes  into  other  solid  organs ; 
that  is,  the  fluid  parts  are  absorbed  and  the  clot  gradually 
becomes  decolorized  until  nothing  but  a  yellowish  mass  of 
fibrin  remains.  Occasionally  it  will  be  of  a  dirty-brown 
color,  resembling  that  found  in  an  old  haematocele  of  the 
tunica  vaginalis  testis. 

Extravasation  of  blood  in  the  ovarian  stroma  occurs 
when  the  ovary  undergoes  axial  rotation. 

Inflammation  of  the  Ovary  (Oophoritis). — Acute  and 
chronic  inflammatory  diseases  of  the  ovaries  are  so  con- 
stantly associated  with  salpingitis,  to  which  they  are  in 
nearly  all  cases  secondary,  that  they  were  considered  in 
Chapter  XXIV. 

There  are  several  conditions  which  it  will  be  necessary  to 
briefly  discuss  here.  They  are —  i .  Oophoritis  secondary  to 
mumps;  2.  Tuberculosis  of  the  ovary;  3.  Abscess  of  the 
ovary. 

I.  Oophoritis  and  Mumps. — Girls  and  young  women 
during  an  attack  of  mumps  occasionally  complain  of  pelvic 
pain.  In  a  few  cases,  where  the  suffering  has  been  suf- 
ficiently severe  to  warrant  a  vaginal  examination,  the  ova- 
ries have  been  found  enlarged,  tender,  and  painful.     As  a 

17 


25'^  DISEASES   OF   WOMEN. 

rule,  the  ovaries  arc  affected  diiriiv^  the  subsidence  of 
mumps.  In  a  few  exceptional  cases  the  pelvic  paiti  has 
preceded  the  parotid  si^ns. 

In  this  connection  it  is  ini])()itant  to  hear  in  mind  that 
parotitis  is  not  infreipiently  a  secpiel  to  injuries  or  operations 
u[)on  abdominal  viscera,  especially  the  pelvic  viscera. 

At  present  there  is  no  explanation  forthcoming  of  the 
relation  of  oophoritis  and  orchitis  as  sequclre  of  mumps. 
Iiuleed,  the  whole  of  the  evidence  rests  on  clinical  ob- 
servation. 

2.  Tuberculosis  of  the  Ovary. — This  disease  may  attack 
the  ovary  in  the  form  of  small  miliary  nodules  limited  to  its 
surface  (as  a  rule,  it  is  then  part  of  a  general  peritoneal 
tuberculosis),  or  it  may  occur  as  a  collection  of  caseous 
pus  in  the  substance  of  the  gland,  and  is  then  secondary 
to  tubercular  salpingitis  (see  Chapter  XXIV.). 

3.  Abscess  of  the  Ovary. — Suppuration  in  the  ovary  is 
in  the  majority  of  cases  secondary  to  salpingitis.  Abscess 
of  the  ovary  apart  from  tubal  infection  may  occur  in  patients 
with  tubercular  lesions  in  other  organs. 

In  one  unusual  case  an  ovarian  abscess  occurring  in  a 
woman  twenty-one  years  of  age  contained  a  piece  of  sew- 
ing-needle 2  cm.  long  (Haviland). 

Treatment. — The  clinical  features  of  ovarian  inflammation 
are  so  bound  up  with  those  of  pyosalpinx  and  its  complica- 
tion that  the  details  will  be  found  in  Chapter  XXV. 

Perioophoritis. — Chronic  inflammation  in  the  pelvis  in 
the  immediate  neighborhood  of  the  ovary  is  almost  sure  to 
involve  this  gland.  Thus  after  pelvic  peritonitis  and  pelvic 
cellulitis  the  superficial  parts  of  the  ovary  are  infiltrated  and 
adhere  to  surrounding  structures.  As  the  inflammatory 
products  organize,  the  ovary  becomes  imbedded  in  tissue 
almost  as  dense  as  that  of  a  cicatrix. 

Perioophoritis  is  said  to  occur  as  a  sequel  to  tx'phoid 
fever,  rheumatism,  the  exanthemata,  and  chronic  alcoholism. 
It  is  occasionally  seen  as  a  consequence  of  ascites. 


DISEASES   OE   JJ/E    OlWRIES.  259 

The  most  important  results  of  perioophoritis  are  painful 
menstruation  (tlysmenorrluea)  and  sterility. 

Cirrhosis  of  the  Ovaries. — Ovaries  are  occasionally 
met  witli  in  women  between  twenty  and  forty  years  of  age 
presenting  a  peculiar  wrinkled  appearance.  Such  ovaries 
are  said  to  be  cirrhotic,  because  the  ultimate  effect  upon  the 
proper  tissue  of  the  ovary  is  similar  to  that  seen  in  hepatic, 
renal,  and  pulmonary  cirrhosis — that  is,  destruction  of  the 
proper  tissue  of  the  liver,  kidney,  or  lung,  as  the  case  may 
be.  The  great  difference  in  fibrosis  of  the  ovary  as  com- 
pared with  this  change  in  other  organs  is,  that  in  the  ovary 
the  connective  tissue  of  the  stroma  shows  no  evidence  of  in- 
flammation. In  a  cirrhotic  liver  the  interstitial  tissue  is  infil- 
trated with  small  round  cells,  but  in  the  cirrhotic  ovaries 
this  is  not  the  case,  even  when  this  change  occurs  in  the 
ovaries  of  a  woman  who  has  also  a  cirrhotic  liver. 

The  changes  described  as  cirrhosis  or  fibrosis  of  the 
ovaries,  occurring  in  women  between  twenty  and  forty 
years  of  age,  require  investigation.  Even  the  cause  or 
causes  producing  the   change  are  imperfectly  understood. 

Ovarian  Neuralgia. — Under  this  term  it  is  usual  to 
consider  a  group  of  symptoms  consisting  mainly  of  pain  in 
the  pelvic  and  subumbilical  regions,  whilst  on  the  most 
careful  physical  examination  nothing  abnormal  can  be  de- 
tected in  the  pelvis  to  account  for  the  painful  symptoms. 

Many  of  the  patients  are  single,  highly  neurotic,  and  com- 
plain of  the  globus  hystericus ;  some  are  highly  religious, 
and  therefore  emotional.  Others  may  be  highly  educated, 
intellectual,  and  interested  in  the  "  fine  arts."  Occasionally 
the  troubles  occur  in  mothers  living  with  their  husbands. 
Unfortunately,  a  large  proportion  of  these  patients  are 
addicted  to  two  vices — alcoholism  and  masturbation. 

The  troubles  do  not  arise  before  puberty,  but  may  occur 
at  any  period  during  sexual  life,  and  in  some  the  symptoms 
are  markedly  accentuated  at  the  menopause. 

The  patient  complains  of  pain  in  one  or  both  iliac  fossae ; 


26o  DISEASES   OF   WOMEN. 

it  is  often  increased  by  the  pressure  of  the  clothes,  by  walk- 
ing, rilling,  or  exercise  in  any  ftjrni ;  some  patients  remain 
confined  to  bed  for  weeks  and  even  months,  and  some 
actually  become  bedridden.  With  many,  sexual  inter- 
course increases  the  pain  ;  in  nearly  all,  the  suffering  is 
worse  during  menstruation. 

Although  these  pains  are  often  described  as  ovarialgia,  it 
is  quite  certain  that  the  ovaries  are  not  the  source  of  the 
painful  sensations,  because  they  have  in  many  instances 
continued,  and  even  become  intensified,  after  bilateral 
oophorectomy.  In  some  the  severity  of  the  symptoms 
has  led  surgeons  to  remove  the  uterus  ;  even  this  extreme 
method  has  failed  to  afford  an  escape  from  the  pain. 

Treatment. — This  is  of  little  avail,  as  may  be  inferred 
from  the  variety  of  methods  which  have  been  employed. 

Nothing  is  so  prejudicial  as  local  treatment :  frequent 
examinations,  the  use  of  vaginal  tampons,  pessaries,  and  all 
kinds  of  electrical  treatment  do  great  harm.  Change  of  air, 
employment,  a  happy  marriage  (especially  if  fertile),  often 
lead  to  improvement. 

Anodynes,  such  as  opium,  morphia,  chloral,  are  danger- 
ous, and  above  all  alcohol  should  be  strictly  forbidden. 

Surgical  measures  are  equally  useless,  for  unilateral  and 
bilateral  oophorectomy  may  do  good  for  a  few  months,  but 
the  almost  inevitable  relapse  leaves  the  patient  worse  than 
before.  Even  sham  oophorectomy  and  vaginal  hysterectomy 
have  been  tried  with  the  same  temporary  success.  These 
patients  are  hopeless  with  physician  and  surgeon,  singly  or 
combined.  Many  become  chronic  alcoholics ;  some  figure 
in  divorce  courts ;  others  end  their  days  in  lunatic  asylums. 


CHAPTER    XXIX. 

DISEASES  OF  THE  OVARIES  (Continued). 

TUMORS,   DERMOIDS,    AND    CYSTS. 

The  ovary  is  a  somewhat  complex  organ  histologically 
and  morphologically,  and  this  fact  explains  in  a  measure 
the  extraordinary  frequency  and  variety  of  the  tumors 
which  arise  therein. 

The  oophoron  contains  a  connective-tissue  stroma  into 
which  strands  of  fibrous  and  muscular  tissue  are  prolonged 
from  the  ovarian  ligament.  From  these  tissues  are  de- 
rived—  I.  Fibromata;  2.  Myomata ;  3.  Sarcomata. 

The  ovary  contains  epithelial  elements  in  its  follicles 
which  are  possible  sources  of — 4.  Carcinoma. 

The  follicles  with  their  rich  epithelium  are  the  sources 
of — 5.  Cysts;  6.  Adenomata;  7.  Dermoids. 

The  paroophoron  is  the  probable  source  of  (8)  papil- 
lomatous cysts,  and  the  persistent  tubules  and  ducts  of 
the  mesonephros  are  the  sources  of  (9)  parovarian  and 
(10)  Gartnerian  cysts. 

1.  Fibromata. — Tumors  composed  entirely  of  firm 
fibrous  tissue  occur  in  the  ovary  and  sometimes  attain 
large  dimensions  (5  kilogrammes).  Many  ovarian  tumors 
reported  to  be  sarcomata  have  on  careful  microscopic 
examination  proved  to  be  fibromata. 

2.  Myomata. — Tumors  of  the  ovary  composed  mainly 
of  unstriped  muscle-fibre  or  a  mixture  of  muscular  and 
fibrous  tissue  are  very  rare. 

Fibromata  and  myomata  of  the  ovaries  occur  as  encap- 
suled  tumors  (Fig.  86),  whereas  the  sarcomata  infiltrate  the 
ovary  throughout. 

261 


262 


DISEASES   OF   WOMEN. 


3.  Sarcomata. — The  ovary  (like  the  kidney  and  retina) 
is  very  prone  to  become  the  seat  of  sarcoma  in  early  life. 
To  this  succeeds  a  period  of  comparative  immunity,  fol- 


FiG.  86.  —  Fibroma  of  the  ovary  (natural  size). 


lowed  by  a  second  period  of  renewed  but  diminished 
liability. 

The  sarcomata  of  infant  life  attack  both  ovaries  in  more 
than  half  the  cases ;  they  grow  rapidly,  attain  formidable 
sizes,  and  quickly  destroy  life. 

Structurally,  they  consist  of  round-  and  spindle-celled 
elements,  in  which  collections  of  cells  are  often  conspicuous, 
resembling  the  alveolar  disposition  characteristic  of  cancer. 
These  supposed  alveoli  are  ovarian  follicles  entangled  in  the 
general  overgrowth  of  the  ovarian  stroma. 

The  first  period  of  exceptional  liability  ends  at  pubert)' ; 


niSKASKS    OF   'I'UE    Ol'AKIKS.  263 

ovarian  sarcomata  arc  very  rare  from  tlic  sixteenth  to  the 
twenty-fifth  year.  From  this  age  to  forty-five  they  arc 
occasionally  met  with,  and  are  in  most  cases  unilateral. 
They  rapidly  destroy  life.  Ascites  complicates  the  last 
stages. 

4.  Carcinoma. — Many  tumors  of  the  ovaries  described 
as  cancers  prove  on  careful  examination  to  be  sarcomata. 
Much  confusion  has  arisen  from  the  fact  that  ovarian  fol- 
licles entangled  amidst  the  sarcomatous  tissue  mimic  the 
structural  peculiarities  of  cancer.  Tumors  of  the  ovary 
occur  in  which  the  chief  changes  are  centred  in  the  follicles, 
and  the  tumors  conform  in  their  clinical  characters  to  carci- 
noma :  they  grow  rapidly  and  infect  the  peritoneum.  Pri- 
mary cancer  of  the  ovary  requires  investigation  with  a  full 
supply  of  material. 

Secondary  Cancer. — It  is  a  curious  rule  that  organs  which 
are  frequently  the  seat  of  primary  cancer  are  rarely  the  seat 
of  secondary  deposits,  and  vice  versa.  To  this  the  ovaries 
are  not  exceptions,  and  it  is  somewhat  remarkable  that  sec- 
ondary cancer  affects  both  organs  in  more  than  half  the 
cases. 

Carcinoma  of  the  mamma,  the  pylorus,  and  the  uterus 
are  the  chief  species  which  lead  to  secondary  deposits  in 
the  ovaries.  Melano-carcinoma  is  apt  to  lead  to  secondary 
nodules  in  one  or  both  ovaries. 

5.  Simple  Cysts. — These  may  be  unilocular  or  multi- 
locular,  and  arise  in  the  ovarian  follicles.  In  a  small  cyst, 
and  in  the  lesser  cavities  of  the  multilocular  variety,  the 
walls  are  lined  with  epithelium,  which  may  be  columnar, 
cubical,  or  stratified  according  to  the  size  of  the  cyst  or 
loculus. 

In  cysts  containing  three  or  four  litres  of  fluid  the  walls 
will  be  found  to  consist  entirely  of  fibrous  tissue ;  no  epi- 
thelium can  be  detected.  It  is  impossible  to  state  definitely 
the  size  of  a  cyst  in  which  the  epithelium  disappears.  The 
absence  of  epithelium  is  due  to  atrophic  changes,  the  conse- 


264 


DISEASES   OE   WOMEN. 


qucncc  of  the  continual  pressure  exerted  by  the  accumulat- 
ing fluid.  Precisely  similar  chan<^es  may  be  studied  in  the 
mucous  membrane  of  greatly  distended  gall-bladders. 
.  An  extremely  simple  means  of  determining  an  oopho- 
ronic  tumor  is  to  note  the  relation  of  the  Fallopian  tube : 
it   lies    curled    up  on    the   cyst,  and  when  the   parts   are 


Fk,    -7. — Ovari.-in  dermoid. 

Stretched  the  tube  and  tumor  are  separated  b}^  the  meso- 
salpinx (Fig.  87). 

A  unilocular  ovarian  cyst  may  attain  an  enormous  size. 
Probably  the  largest  on  record  was  removed  (by  Dr.  Eliza- 
beth Reifsnyder,  a  lady  missionary  at  Shanghai)  from  a 
Chinese  woman  twenty-five  years  of  age.  The  sac  yielded 
100  litres  of  fluid  and  the  patient  recovered. 


D IS F. ASKS   OF   THE    OVARIES. 


265 


6.  Adenomata. — These  arc  important  and  interesting 
tumors.  They  possess  a  fibrous  capsule,  and  internally  con- 
sist of  a  great  number  of  loculi,  some  of  which  will  scarcely 
accommodate  a  pea,  whilst  others  hold  a  litre  or  more  of 
fluid. 

The  loculi  in  the  early  stages  of  growth  are  lined  with 
tall  columnar  epithelium  and  the  walls  contain  mucous 
glands.  In  some  tumors  the  lining  membrane  is  indistin- 
guishable from  mucous  membrane.  The  fluid  contained  in 
such  loculi  is  identical  with  mucus,  and  it  varies  in  consist- 
ency from  that  of  the  "  white  of  an  &gg  "  to  the  gluey  con- 
dition of  jelly. 

Ovarian  adenomata  attain  enormous  dimensions — thirty, 
forty,  and  even  fifty  kilogrammes. 

7.  Dermoids. — A  very  large  proportion  of  cysts  arising 
in  the  oophoron  contain  skin  or  mucous  membrane,  or  both 


Teeth  and  bone  from  an  ovarian  dermoid. 


these  structures,  and  some  of  the  many  organs  arising  from 
and  peculiar  to  them,  such  as  hair,  sebaceous,  sweat,  mu- 
cous, and  mammary  glands,  as  well  as  bone,  horn,  nails, 
and  teeth  (Figs.  88,  89).  Tumors  of  this  kind  are  called 
dermoids.  They  may  be  unilocular  or  multilocular,  and 
attain  a  weight  of  twenty,  or  even  forty,  kilogrammes. 
It  is  necessary  to  indicate  how  impossible  it  is  to  separate 


266 


DISEASES   OE   WOMEN. 


the  three  varieties — cysts,  adenomata,  and  dermoids — from 
each  other.  Occasionally  a  tumor  will  come  to  hand  dis- 
playing an  internal  lining  of  stratified  epithelium  which 
would  serve  for  skin  or  mucous  membrane,  yet  if  it  possess 
a  iew  hairs  it  is  called  skin  and  the  cyst  becomes  a  dermoid. 


Fig.  89. 


-Microscopic  cliaracters  of  liair,  sebaceous  glands,  and  sweat-glands  from  an  ova- 
rian dermoid  {\.  E.  G.). 


The  contents  of  a  dermoid  usually  consist  of  a  pultaceous 
mi.xturc  of  shed  epithelium,  fat,  and  shed  hair.  In  some 
complex  multilocular  dermoids  some  of  the  loculi  contain 
mucous  membrane  and  are  filled  with  mucus  ;  others  pos- 
sess hairs  ;  and  a  few  may  be  quite  barren. 

It  is  impossible  to  determine  in  many  cases,  from  a  mere 
naked-eye  examination,  whether  an  oophoronic  tumor 
should  be  regarded  as  an  adenoma  or  a  dermoid.     In  prac- 


DISEASES   OE   THE    OVARIES. 


267 


ticc  the  presence  of  a  tuft  of  hair  or  a  tootli  is  a  useful  and 
ready  way  of  settlinij  the  question.  Failing  this,  a  careful 
microscopical  examination  is  necessary. 


Fig.  90. — Large  ovarian  dermoid  in  a  girl  seven  years  old  (Dandois). 

Cysts  of  the   oophoron   occur  at  all  periods  of  life,  and 
even  in  young  girls  sometimes  reach  a  great  size  (Fig.  90). 


268  DISEASES  OF   WOMEN. 

In  some  instances  the  tumor  will  weigh  more  than  the  body 
of  the  patient.  In  one  case  a  j^irl  weighed  27  kilos  and  her 
tumor  44  kilos  (Keen).  Ovarian  dermoids  have  been  seen 
as  early  as  the  first  year  of  life  and  as  late  as  eighty-three. 
There  is  no  authentic  record  of  an  ovarian  deruKjid  in  a 
foetus. 

Maliguancy  of  Adenomata  aud  Dermoids. — It  has  been 
supposed,  on  inadequate  evidence,  that  these  tumors  some- 
times exhibit  malignant  characters.  It  is  a  curious  fact 
that  when  a  loculus  of  a  dermoid  bursts  into  the  ccelom  the 
epithelium  is  liable  to  become  engrafted  on  the  peritoneum 
and  give  rise  to  secondary  tumors.  There  is  no  evidence 
based  on  post-mortem  examination  that  after  the  removal 
of  an  ovarian  dermoid  recurrence  has  taken  place  in  the 
stump.  It  is  a  fact  that  in  women  dermoids  have  never 
been  found  growing  primarily  from  any  abdominal  viscus 
save  the  ovary. 

It  is  important  for  the  student  to  recognize  that  all  the 
curious  structures  found  in  ovarian  dermoids  are  peculiar  to 
skin  or  mucous  membrane.  Organs,  such  as  liver,  kidney,' 
and  intestine,  or  limbs  and  bones  of  definite  shape,  such  as 
the  femur,  humerus,  vertebrae,  or  skull-bones,  are  never 
found.  The  fact  serves  to  sharply  distinguish  dermoids 
from  teratomata,  which  are  derived  from  suppressed  em- 
brj^os. 

Confusion  has  occasionally  been  introduced  when  a  care- 
less observer  has  mistaken  a  lithopa.'dion,  the  result  of  a 
tubal  pregnane)',  for  a  dermoid.  On  the  other  hand,  o\a- 
rian  dermoids  have  been  mistaken  for  the  products  of  what 
used  to  be  vaguely  called  "  extra-uterine  gestation." 

Ovarian  dermoids  have  also  been  regarded  as  a  kind  of 
imperfect  pregnancy.  It  is,  however,  open  to  any  one  pos- 
sessing average  patience,  ordinary  capacity  for  obser\'ation, 
and  the  usual  training  in  histology  to  demonstrate  to  his 
own  satisfaction  that  the  epithelium  of  the  o\arian  follicle 
is  the  source  of  all  the  structures  found  in  ovarian  dermoids, 


DISEASES   OE   THE    OVARIES. 


269 


and  that  such  curious  expressions  as  parthenoc^encsis,  im- 
perfect conceptions,  luciiia  sine  concubitu,  excess  of  forma- 
tive energy,  etc.,  which  have  encompassed  this  question 
with  such  clouds  of  mystery,  must  yield  to  deductions 
from  accurately  observed  facts. 

8.  Papillomatous  Cysts. — These  differ  from  simple 
cysts  of  the  ovary  in  the  fact  that  they  are  invariably  uni- 
locular and  their  inner  walls  are  beset  with  warts  (papil- 
lomata,  Fig.  91).    They  also  differ  from  the  three  preceding 


Fig.  91. — Papillomatous  cyst. 

species  in  the  fact  that  there  is  reason  to  believe  that  they 
arise  in  the  paroophoron. 

These  cysts  do  not  affect  the  shape  of  the  ovary  until 
they  have  attained  an  important  size :  they  always  burrow 
between  the  layers  of  the  mesosalpinx,  and,  when  large, 
make  their  way  between  the  layers  of  the  mesometrium  by 
the  side  of  the  uterus.  Papillomatous  cysts  are  most  fre- 
quent between  the  twenty-fifth  and  fiftieth  years.  The 
warts    vary  greatly  in    number :    some    cysts    contain    but 


2/0 


DISEASES   OF   WOMEN. 


few ;  in  others  they  arc  so  luxuriant  as  to  cause  the  cyst  to 
burst;  tlic  warts  then  protrude  as  soft  dendritic  vascular 
masses,  and  the  surface  cells  become  detached  and  enj^raft 
themselves  on  the  peritoneum  and  form  secondary  warts. 
This  accident  is  usually  followed  by  hydroperitoneum. 

9.  Parovarian  Cysts. — These  are  of  two  kinds:  the 
most  frequent  are  small  pedunculated  cysts  arising  in 
Kobelt's  tubes ;  they  are  of  no  clinical  interest. 

The  most  important  cysts  are  sessile  and  remain  between 

Fallopian  tube. 


Ovary. 


Fig.  92. — Parovarian  cyst. 


the  layers  of  the  mesosalpinx.     When  the  cyst  is  large  the 
Fallopian  tube  is  stretched  across  its  crown  (Fig.  92). 

Small  parovarian  cysts  arc,  as  a  rule,  transparent,  but 
when  they  exceed  the  size  of  a  cocoanut  the  cyst-walls 
become  thick  and  opaque.  Small  cysts  arc  lined  with 
columnar  epithelium,  which  is  sometimes  ciliated  ;  in  cysts 


DISEASES   OE   THE    OVARIES.  27  I 

of  moderate  size  the  epitheliuni  becomes  stratified,  and  in 
large  cysts  it  disappears. 

The  fluid  they  contain  is  hnipid  and  slightly  opalescent ; 
specific  gravity,  1002  to  1007 ;  reaction  slightly  alkaline. 
A  substance  precipitated  by  alcohol  is  present  in  large 
quantity. 

In  large  cysts  the  fluid  is  often  turbid  and  may  contain 
cholesterine.  When  parovarian  cysts  rupture  into  the  ccelom 
(peritoneal  cavity)  the  fluid  is  quickly  absorbed  and  excreted 
by  the  kidney.s. 

The  chief  anatomical  points  which  enable  a  parovarian  to 
be  distinguished  from  an  oophoronic  cyst  are — 

1.  The  peritoneal  coat  is  easily  stripped  off; 

2.  The  ovary  is  usually  attached  to  the  side  of  the  cyst ; 

3.  The  cyst  is,  as  a  rule,  unilocular ; 

4.  The  Fallopian  tube  is  tightly  stretched  across  the 

cyst  and  does  not  communicate  with  it. 

The  age  at  which  parovarian  cysts  occur  is  of  some  in- 
terest. It  has  already  been  mentioned  that  cysts  of  the 
oophoron  are  encountered  at  any  period,  from  fa^tal  life  up 
to  extreme  old  age.  The  occurrence  of  a  parovarian  cyst 
has  not,  so  far,  been  recorded  in  an  individual  before  the 
age  of  sixteen.  Many  undoubted  cases  have  been  observed 
at  seventeen,  eighteen,  and  nineteen,  the  cysts  being  large 
enough  to  rise  above  the  pubes.  Before  sixteen  the  paro- 
varium appears  to  be  quiescent,  but  on  the  advent  of  puberty 
it  seems  to  undergo  great  stimulation  ;  a  very  large  propor- 
tion of  cysts,  generally  classed  as  ovarian,  removed  between 
the  ages  of  seventeen  and  twenty-five,  arise  in  this  interest- 
ing structure. 

10.  Gartnerian  Cysts. — There  are  good  reasons  to 
believe  that  some  papillomatous  cysts  of  the  mesometrium_ 
especially  those  which  burrow  deeply  by  the  side  of  the 
uterus,  arise  in  persistent  portions  of  Gartner's   duct. 

Cysts  of  this  character  which  burrow  deeply  often  entail 
risk  in  removal,  as  they  lie  in  intimate  relation  with  uterus, 


2/2  DISEASES    OJ-    WOMEN. 

ureter,  and  bladder:  the  cyst  when  large  will  come  in  con- 
tact with  the  iliac  arteries  and  veins  at  the  brim  of  the  pelvis, 
and  even  rest  upon  the  inferior  vena  cava. 

Gartnerian  cysts  arising  in  the  terminal  segment  of  the 
duct  project  into  the  vagina.  In  some  instances  these  cy.sts 
may  be  treated  surgically  through  the  vagina  with  greater 
success  than   by  cceliotomy. 

Ovarian  Hydrocele. — In  many  mammals  the  ovary 
is  surrounded  by  a  tunic  of  peritoneum  resembling  the  tu- 
nica vaginalis  testis.  The  Fallopian  tube  opens  into  this 
cavity ;  thus  the  ova  reach  the  uterus  without  entering  the 
coelom  (peritoneal  cavity).  Occasionally  this  peritoneal 
pocket  becomes  distended  with  fluid,  and  is  conveniently 
called  an  ovarian  hydrocele.  Such  a  cyst  is  vj|:ry  rare  in 
women  :  many  specimens  described  as  ovarian  hydroceles 
are  very  large  examples  of  hydrosalpinx. 


CHAPTER   XXX. 

DISEASES   OF   THE   OVARIES    (Continued). 

SECONDARY    CHANGES    IN    OVARIAN 
TUMORS. 

Many  of  the  secondary  changes  to  which  ovarian  tumors 
are  hable  imperil  Hfe.  The  chief  changes  are — i.  Septic 
infection  ;  2.  Axial  rotation ;  3.  Rupture. 

I .  Septic  Infection. — When  air  or  intestinal  gases  gain 
access  to  ovarian  cysts,  then  suppuration  with  all  its  attend- 
ant evils  is  the  consequence.  Contamination  may  arise  from 
puncture  with  a  trocar  or  aspirating  needle.  More  fre- 
quently it  is  due  to  the  entrance  of  gases  from  the  intes- 
tine, due  to  adhesion  of  the  tumor  to  an  adjacent  coil  of 
bowel,  or  to  the  vermiform  appendix ;  or  to  infection  from 
the  Fallopian  tube. 

The  result  of  the  suppuration  is  to  set  up  almost  universal 
adhesions  to  surrounding  structures ;  in  acute  cases  severe 
.symptoms  arise,  and  unless  the  pus  finds  an  exit  the  patient 
dies.  Even  when  the  pus  finds  an  outlet  the  patient  leads  a 
miserable  existence,  becomes  emaciated  by  the  prolonged 
discharge,  and  dies  worn  out  by  suffering. 

In  acute  suppuration  of  a  large  ovarian  cyst  the  symptoms 
are  very  characteristic.  The  patient  presents  the  usual 
signs  of  an  ovarian  tumor,  with  pain  and  tenderness  on 
pressure;  the  pulse  is  rapid  and  feeble  and  accompanied  by 
great  emaciation  and  exhaustion.  The  temperature  is  at 
jfirst  high — .standing  at  100°  or  102°  F.  in  the  morning  and 
rising  to  103°  to  105°  in  the  evening.  As  the  patient  be- 
comes more  and  more  exhausted  toward  the  close  of  the 

13  273 


2/4  DISEASES   OE   WOMEN. 

case  the  temperature  may  fall,  and  has  been  recorded  as 
low  as  95°  F.  This  low  temperature  has  been  observed  in 
cases  where  the  pus  was  unusually  offensive.  In  many 
cases  the  urine  contains  albumin.  The  cyst  sometimes 
contains  gas;  under  such  conditions  the  tumor-dulness  is 
replaced  by  a  hii^hly  tympanitic  note.  It  is  a  fact  of  some 
interest  that  suppurating  ovarian  cysts  have  given  rise  to 
signs  simulating  typhoid  fever,  and  the  patient  has  been 
treated  for  this  disease  until  the  accidental  discovery  of  the 
tumor  made  the  case  clear.  Suppuration  of  an  ovarian  cyst 
has  followed  an  attack  of  typhoid  fever,  and  typhoid  bacilli 
have  been  found  in  the  pus. 

Stippurating  dcrjiwids  of  the  ovary  are  by  no  means  in- 
frequent, and,  like  other  forms  of  ovarian  cysts,  when  in- 
flamed they  become  firmly  adherent  to  surrounding  struc- 
tures. They  may  burst  into  the  ccclom,  the  rectum,  bladder, 
vagina,  or  even  through  the  abdominal  wall  near  Poupart's 
ligament,  or  at  the  umbilicus. 

Adliesions,  from  whatever  cause  arising,  are  a  source  of 
anxiety  to  the  operator  when  they  are  abundant.  A  few 
straggling  omental  adhesions  are  of  no  moment,  or  a  few 
fibrous  bands  connecting  the  cyst  to  the  anterior  abdominal 
wall ;  but  when  traqts  of  small  intestine  or  colon  are  firmly 
united  to  the  cyst-wall  by  broad  fibrous  bands,  or  the  tumor 
is  fixed  to  the  pelvic  peritoneum  by  dense  adhesions,  the 
task  of  removing  the  tumor  is  very  anxious,  tedious,  and 
occasionally  impossible. 

The  mode  by  which  adhesions  arise  is  identical  with  the 
process  by  which  bands  form  in  connection  with  the  intes- 
tines. The  peritoneum  becomes  inflamed,  and  the  exuda- 
tion which  accompanies  that  process — the  so-called  lymph 
— organizes  and  undergoes  slow  conversion  into  fibrous 
tissue.  When  the  parts  united  b}'  this  material  remain  in 
apposition  whilst  it  organizes,  a  sessile  adhesion  results. 
When  there  is  movement  between  the  parts  during  the  pro- 
cess, then    the    uniting   material    becomes    elongated    into 


DISEASES   OF  THE    OVARIES.  2^$ 

bands,  broad  or  narrow  according  to  the  extent  of  surface 
involved. 

2.  Axial  Rotation. — Abdominal  tumors  of  all  kinds  are 
liable  to  turn  round  on  their  axes — a  movement  which  leads 
to  twisting  (or  torsion)  of  the  pedicle  and  interferes  with 
the  circulation  in  the  tumor.  Ovarian  tumors,  large  and 
small,  are  very  liable  to  rotate.  This  movement  frequently 
occurs  when  an  ovarian  tumor  complicates  pregnancy  or  a 
uterine  myoma :  it  has  been  especially  noticed  to  follow  the 
diminution  in  size  of  the  uterus  after  delivery  at  term  or 
abortion. 

Rotation  of  a  cyst  in  the  early  stages  of  pregnancy  is 
probably  due  to  the  gradual  enlargement  of  the  uterus  dis- 
placing the  tumor  upward  :  as  the  pressure  is  exerted  upon 
one  side  of  the  cyst,  it  would  be  in  a  favorable  position  to 
impart  a  rotary  motion  to  a  non-adherent  cyst. 

The  amount  of  rotation  varies  greatly.  In  some  cases 
the  cyst  has  only  turned  through  half  a  circle ;  in  others  as 
many  as  twelve  complete  twists  have  been  counted.  The 
direction  of  the  rotation  may  be  from  right  to  left,  or  vice 
versa,  but  cysts  exhibit  a  stronger  tendency  to  rotate  toward 
the  middle  line  than  away  from  it.  Tumors  of  the  right 
and  left  side  are  equally  liable  to  rotate. 

The  effect  of  torsion  on  the  circulation  depends  on  the 
tightness  of  the  twist,  and  this  varies  with  the  thickness 
of  the  pedicle.  The  vessels  in  a  long,  thin  pedicle  would 
suffer  obstruction  quicker  than  those  in  a  short  and  thick 
one.  When  a  pedicle  is  twisted  the  thin-walled  veins  be- 
come compressed,  whilst  the  more  resilient  arteries  continue 
to  convey  blood  to  the  cyst.  The  result  is  severe  venous 
engorgement,  and  this  leads  to  extravasation  of  blood  into 
the  cyst-wall ;  in  many  cases  the  veins  rupture  and  hemor- 
rhage takes  place  into  the  cavity  of  the  cyst.  The  hemor- 
rhage may  be  so  profuse  as  to  cause  profound  anaemia,  and 
even  death.  Cases  have  been  reported  in  which  a  patient 
has  died  in  a  few  hours  from  this  cause. 


276  DISEASES   OF   WOAfEN. 

Occasionally  the  tumor  will  become  completely  detached 
from  its  pedicle  in  consequence  of  torsion. 

The  signs  of  acute  rotation  of  an  ovarian  cyst  arc  often 
so  characteristic  as  to  lead  to  a  correct  diagnosis.  When  a 
woman  complains  of  sudden  and  violent  pain  in  the  abdo- 
men, accompanied  with  vomiting,  and  she  is  known  to  have 
an  ovarian  tumor,  or  she  presents  herself  for  the  first  time 
to  the  surgeon,  and  these  signs  are  associated  with  an  ab- 
dominal swelling,  the  physical  signs  of  which  are  indicative 
of  an  ovarian  tumor,  axial  rotation  should  be  suspected. 
When  the  patient  has  an  ovarian  tumor  and  is  pregnant,  or 
has  been  recently  delivered,  this  is  an  additional  reason 
for  suspecting  that  the  symptoms  arise  from  a  twisted 
pedicle. 

It  is  important  to  remember  that  the  predominant  signs 
of  acute  axial  rotation  of  abdominal  organs  and  tumors  are 
those  common  to  a  strangulated  hernia  minus  stercoraceous 
vomiting,  and  even  this  will  be  present  should  a  piece  of 
gut  be  involved  in  the  twists  of  the  pedicle. 

3.  Rupture. — Ovarian  cysts  are  liable  to  burst  into  the 
ccelom  either  without  any  obvious  cause  (spontaneous  rup- 
ture) or  from  violence  ;  for  example,  during  "  an  immoderate 
fit  of  laughter,"  or-  whilst  stooping  to  "  button  the  boots," 
during  vomiting,  coughing,  the  manipulation  of  a  physi 
cian,  or  a  fall. 

The  signs  of  rupture  of  an  ovarian  cyst  are — (c?)  Sudden 
accession  of  pain,  accompanied  by  alteration  in  the  shape 
of  the  tumor  ;  {li)  Subsequent  profuse  diuresis  ;  (r)  Gradual 
reaccumulation  of  the  fluid  in  the  cyst. 

The  results  of  such  an  accident  depend  on  the  nature  of 
the  cyst.  The  rupture  of  a  parovarian  cyst  is  not  attended 
with  ill  effects  ;  the  cyst  may  refill  and  burst  repeatedly. 

When  the  rupture  of  an  ovarian  cyst  is  due  to  axial  ro- 
tation, then  the  patient  may  die  from  hemorrhage.  In  the 
case  of  an  adenoma  the  mucoid  material  forms  a  curious 
sago-like  deposit  on  the  peritoneal  surface  of  the  viscera. 


DISEASES   OF   THE    OVARIES.  277 

In  rare  cases,  cells  from  a  dermoid  will  become  engrafted 
on  the  peritoneum  and  form  secondar}'  dermoids. 

The  rupture  of  papillomatous  cysts  is  invariably  followed 
by  secondary-  warts  on  the  peritoneum  and  hydroperito- 
neum.  When  suppurating  cysts  burst  into  the  caelom, 
rapidly  fatal  peritonitis  is  the  consequence. 

Ovarian  cysts,  especially  dermoids,  may  burst  into  hol- 
low viscera,  usually  the  rectum  or  the  bladder.  When  the 
contents  of  a  dermoid  escape  into  the  bladder,  it  is  a  source 
of  great  misery,  as  the  hair,  teeth,  or  bones  serve  as  nuclei 
for  phosphatic  deposits. 

Modes  of  Death. — Tumors  of  the  ovaries  are  now  so 
promptly  removed  when  discovered  that  there  are  happily 
few  opportunities  of  studying  the  way  in  which  they  destroy 
life.  It  will  be  useful  to  enumerate  the  modes  of  death  :  i. 
Pressure  on  ureters,  hydronephrosis,  uraemia ;  2.  Cystitis, 
pyelitis  ;  3.  Intestinal  obstruction  ;  4.  Suppuration  of  cyst, 
septicaemia;  5.  Peritonitis  from  leakage  into  the  coelom ;  6. 
Large  cysts  impede  respiration  by  pushing  up  the  dia- 
phragm and  compressing  the  lungs  ;  7.  Hemorrhage  from 
rupture  of  cyst ;  8.  Impediment  to  labor. 

Symptoms  and  Diagnosis. — The  symptoms  which  in- 
duce women  with  ovarian  tumors  to  seek  advice  var}-  with 
their  size.  When  the  tumor  is  restricted  to  the  pelvis,  the 
troubles  it  may  cause  are  different  to  those  it  may  produce 
when  it  is  large  enough  to  rise  abo\e  the  pelvic  brim  and 
occupy  .the  abdomen.  When  the  tumor  is  large  enough  to 
rise  up  out  of  the  pelvis  the  only  troublesome  symptom,  in 
a  very  large  number  of  cases,  is  progressive  enlargement 
of  the  belly.  This,  in  a  married  woman,  is  often  attributed 
to  pregnancy ;  in  young  unmarried  women  it  is  a  source  of 
annoyance,  as  it  leads  occasionally  to  a  suspicion  of  preg- 
nancy. At  other  times  the  pressure-effects  induced  by 
ovarian  tumors,  such  as  troubles  with  the  bladder,  hydro- 
nephrosis, oedema  of  the  leg,  and  dyspnoea,  induce  patients 
to  seek  advice. 


278  DISEASES   01'    WOMEN. 

When  the  tumor  is  small  enough  to  be  accommodated  in 
the  pelvis,  it  causes  trouble  by  becoming  impacted  and  ex- 
ercising baneful  pressure  on  bladder,  ureters,  rectum,  and 
intestines. 

Should  complications  arise  (such  as  axial  rotation,  inflam- 
mation, or  suppuration  of  the  cyst),  they  will  lead  to  detec- 
tion of  the  tumor. 

In  a  typical  case  of  ovarian  tumor  the  size  of  the  abdomen 
is  increased.  With  a  big  cyst  the  enlargement  is  general, 
but  when  the  tumor  is  of  moderate  dimensions  it  is  localized 
to  one  or  other  flank.  Local  enlargements  due  to  ovarian 
tumors  are  always  most  marked  below  the  level  of  the  um- 
bilicus. The  skin  of  the  abdomen  sometimes  presents  a 
brown  discoloration  and  the  superficial  veins  may  be  dis- 
tended. 

On  palpatio7i  the  swelling  feels  firm  and  resisting.  In 
cystic  tumors  its  surface  is  uniform,  as  a  rule,  but  multi- 
locular  cysts  may  have  an  irregular  surface  ;  this  is  also  true 
of  ovarian  adenomata.  Manipulation  rarely  causes  pain. 
In  large  cysts  a  wave  of  fluctuation  can  easily  be  produced  ; 
in  multilocular  cysts  the  sign  is  restricted  to  large  cavities. 
The  distinctness  with  which  the  wave  is  perceived  depends 
upon  the  character  of  the  fluid  and  the  thickness  of  the 
abdominal  wall. 

Percussion  furnishes  valuable  evidence.  The  crown  and 
sides  of  the  swelling  are  quite  dull,  but  on  approaching  the 
loins  the  dulness  gradually  gives  way  to  resonance.  If  now 
the  patient  be  turned  to  one  or  other  side,  we  shall  find  that 
the  alteration  in  position  does  not  affect  the  percussion-note. 
In  those  exceptional  cases  where  the  cyst  communicates 
with  intestine  the  swelling  yields  a  tympanitic  note  on  per- 
cussion, due  to  the  presence  of  intestinal  gas. 

Auscultation,  as  a  rule,  gives  no  information.  Gurgling 
of  intestines  and,  occasionally,  the  pulsation  of  the  aorta 
may  be  perceived,  and  very  rarely  a  bruit  has  been  detected. 
In  non-ovarian  tumors  this  method  of  physical  examination 


DISEASES   OF  THE    OVARIES.  lyC) 

often  aflbrds  valuable  information.  After  examining  the 
abdomen  the  surgeon  should  explore  the  parts  by  an  in- 
ternal examination.  As  a  rule,  this  is  best  made  through 
the  vagina,  but  in  young  unmarried  girls  it  will  sometimes 
be  necessary  to  make  the  examination  by  the  rectum.  In 
this  way  the  surgeon  ascertains  the  relation  of  the  tumor  to 
the  uterus,  the  condition  of  this  organ,  and  the  state  of  the 
rectum.  In  uncomplicated  cases  of  ovarian  tumor  the  in- 
formation furnished  by  a  vaginal  or  rectal  examination  is 
negative,  but  it  should  always  be  undertaken. 

The  recognition  of  a  large,  uncomplicated  ovarian  cyst 
is  one  of  the  simplest  processes  in  clinical  surgery.  The 
signs  may  be  thus  summarized  :  A  swelling  of  the  abdomen, 
most  marked  below  the  umbilicus,  associated  with  absolute 
dulness  to  percussion  all  over  the  tumor,  most  marked  on 
its  summit,  and  fading  away  to  resonance  in  the  flanks ; 
such  dulness  is  not  affected  by  alteration  in  the  position  of 
the  patient.  If  such  signs  be  associated  with  a  uterus  of 
normal  size,  the  presumption  that  the  swelling  is  an  ovarian 
tumor  is  as  certain  as  most  things  in  clinical  medicine. 

The  diagnosis  of  simple  cases  of  ovarian  tumor  rarely 
gives  rise  to  difficulty  if  the  surgeon  duly  weighs  the  various 
signs  together,  and  does  not  place  too  much  reliance  on  any 
one  of  them.  Difficulty  arises  sometimes  in  distinguishing 
between  ovarian  tumors  and  conditions  which  simulate 
them ;  the  greatest  care  and  skill  is  needed  when  diagnosis 
is  complicated  by  secondary  changes  in  the  cyst  and  by  the 
coexistence  of  other  tumors,  abnormal  conditions  of  the 
abdominal  viscera,  ascites,  or  pregnancy. 

The  diagnosis  of  ovarian  tumors  involves  the  question  of 
the  diagnosis  of  abdominal  swellings  in  general.  Indeed, 
there  is  no  organ  in  the  belly  which  has  not  at  some  time 
or  other  given  rise  to  signs  resembling  those  presented  by 
an  ovarian  cyst.  These  facts  alone  will  serve  to  show  that 
there  is  no  pathognomonic  sign  indicative  of  an  ovarian 
tumor.     In  many  cases  the  methods  of  physical  examina- 


28o  DISEASES   OE   WOMEN. 

tion  arc  incompetent  to  enable  us  to  form  a  correct  opinion 
of  the  nature  of  an  abdominal  tumor  until  it  has  been 
actually  exposed  to  view ;  even  when  the  abdomen  is 
opened,  doubts  and  difficulties  sometimes  arise.  It  will  be 
useful  to  mention  the  various  conditions  which  have  been 
mistaken  for  ovarian  tumors,  and  vice  versa. 


CHAPTER    XXXI. 

DISEASES  OF  THE  OVARIES   (Continued). 

DIFFERENTIAL    DIAGNOSIS    AND    TREAT- 
MENT   OF    OVARIAN    TUMORS. 

Method  of  Examination. — When  a  woman  suspected 
of  an  abdominal  tumor  comes  under  observation,  it  is  the 
duty  of  the  surgeon  or  physician,  as  the  case  may  be,  to 
inquire  into  the  history  of  the  case.  Information  concern- 
ing the  age,  social  condition,  and  menstrual  history  is  often 
as  important  in  diagnosis  as  a  knowledge  of  the  general 
physical  condition  of  the  patient  and  the  facts  she  may  be 
able  to  relate  concerning  the  tumor  itself 

In  conducting  the  physical  examination  of  the  patient  she 
should,  whenever  possible,  be  undressed,  for  nothing  is  so 
unsatisfactory  as  examining  an  abdomen  to  ascertain  the 
existence  or  nature  of  a  tumor  when  the  parts  are  encum- 
bered by  partially  loosened  skirts,  stays,  petticoats,  and 
other  garments. 

The  patient  should  be  placed,  when  undressed,  with  her 
back  flat  upon  a  bed  or  couch  and  the  legs  covered  with 
a  sheet  or  blanket.  The  surgeon  should  be  careful  that 
his  hands  and  finger-tips  are  warm,  as  cold  fingers  are 
very  uncomfortable  to  the  patient  and  hinder  a  proper  ex- 
amination. 

At  the  outset  he  first  attempts  to  assure  himself  of  the 
existence  of  an  abdominal  swelling  by  employing  his  eyes, 
aided  by  palpation  and  percussion ;  often  auscultation  ren- 
ders important   assistance. 

Tumors  are  often  simulated  by  obesity,  and  an  accumu- 

281 


282  D/SF..iSKS   OF   irOMKX. 

lation  of  subcutaneous  fat  has  so  deceived  surgeons  that  in 
several  recorded  cases  the  abdomen  has  been  opened  before 
the  character  of  the  enlargement  was  recognized. 

The  strangest  of  all  conditions  simulating  tumor  is  the 
"puffing  up  of  the  belly"  known  as  phantom  tumor, 
where  a  woman  thinks  she  is  pregnant  or  suffering  from  a 
tumor.  To  avoid  error,  it  is  only  necessary  to  be  aware 
of  the  possibility  of  the  condition.  On  percussion  the  belly 
is  everywhere  resonant,  and  by  cautiously  engaging  the 
patient  in  conversation  during  the  manipulation  the  belly 
becomes  quite  flat.  If  after  physical  examination  the  sur- 
geon is  unable  to  decide  the  question  with  certaint)',  he 
should  arrange  for  the  administration  of  an  amesthetic  :  as 
the  woman  becomes  unconscious  the  swelling  diminishes, 
then  the  belly  becomes  flat ;  as  consciousness  returns  the 
swelling  of  the  belly  reappears. 

Phantom  tumor  is  liable  to  occur  in  sterile  women  who 
have  married  late  in  life,  and  especially  in  women  who  have 
a  morbid  desire  for  pregnancy.  It  is  occasionally  met  with 
in  women  who  have  borne  children,  and  now  and  then  in 
young  wives.  Sometimes  it  is  seen  in  women  who  have  sub- 
jected themselves  to  illicit  intercourse  and  fear  the  results. 

It  is  difficult  to  understand  how  this  condition  could  be 
mistaken  for  an  abdominal  tumor,  yet  more  than  one  case 
has  been  recorded  in  which  the  abdomen  was  opened  to 
remove  the  supposed  tumor.  Most  of  the  cases  occurred 
in  the  early  days  of  ovariotomy,  and  now  that  surgeons  are 
fully  aware  of  the  condition,  and  with  the  assistance  afforded 
by  an  anajsthetic,  such  blunders  are  not  likely  to  be  made. 

Pregnancy,  normal  and  abnormal,  and  uterine  tu- 
mors, often  simulate  ovarian  tumors  (see  p.  193).  The 
remaining  conditions  which  are  apt  to  be  mistaken  for  ova- 
rian tumors  are  the  following  : 

1.  Ascites  and  hydroperitoneum  ; 

2.  Distended  bladder ; 

3.  Faecal  accumulation ; 


DISEASES   OF   THE    OVARIES.  283 

4.  Renal  cysts  and  tumors  ; 

5.  Splenic  enlargement  and  tumors  ; 

6.  Morbid  condition  of  the  gall-bladder; 

7.  Cysts  of  the  pancreas,  mesentery,  or  omentum ; 

8.  Lipomata ; 

9.  Echinococcus  cysts. 

Ascites. — An  accumulation  of  free  fluid  in  the  Lelly  is, 
as  a  rule,  easily  distinguished  from  an  abdominal  tumor,  but 
many  instances  have  been  recorded  in  which  ascites  has 
been  mistaken  for  an  ovarian  cyst,  and  vice  versa. 

A  well-marked  case  of  ascites  rarely  causes  difficult)'  in 
diagnosis.  The  abdomen  is  uniformly  enlarged  :  when  the 
patient  lies  on  her  back  the  fluid  occupies  the  flanks,  and 
when  abundant  the  sides  of  the  belly  form  a  convex  curve 
from  the  lower  ribs  to  the  crest  of  each  ilium.  On  percus- 
sion the  flanks  and  lower  half  of  the  abdomen  are  dull, 
whilst  around  the  umbilicus  a  clear  resonant  note  is  ob- 
tained. If  the  patient  be  now  turned  to  one  or  other  side, 
the  conditions  are  reversed ;  the  higher  flank  becomes  reso- 
nant and  the  umbilical  region  dull.  This  shifting  dulness 
is  the  most  characteristic  sign  of  ascites.  In  addition,  when 
the  fluid  is  present  in  sufficient  quantity,  a  percussion  wave 
may  be  easily  produced  from  side  to  side. 

When  free  fluid  in  the  coelom  is  associated  with  second- 
ary cancer  or  the  presence  of  a  tumor,  innocent  or  malig- 
nant, then  the  diagnosis  may  be  difficult.  This  condition 
is  discussed  in  the  chapter  on  Hydroperitoneum. 

Attempts  have  been  made  to  detect  among  the  fluids 
found  in  the  belly  and  in  cysts  of  the  ovary,  characters 
(chemical,  microscopic,  or  spectroscopic)  which  would  serve 
to  distinguish  them  from  each  other,  but  to  no  purpose. 

Distended  Bladder. — It  is  of  the  first  importance  in  in- 
vestigating a  doubtful  case  of  abdominal  tumor  to  obtain  a 
sample  of  the  urine,  and  to  ascertain  the  quantity  as  well  as 
the  quality  of  the  secretion.  An  overfull  bladder  has  a 
striking  pyriform  shape,  and   may  extend  as   high  as  the 


284  DISEASES   OF   WOMEN. 

navel  and  simulate  a  tumor.  Such  over-distention  may  be 
due  to  pressure  on  the  urctiira  from  a  pelvic  tumor  or  a 
retroverted  (incarcerated)  gravid  uterus. 

FcBcal  acaumdation  (coprostasis)  in  the  rectum,  cajcum, 
or  colon  will  simulate  an  abdominal  tumor.  Copious  enem- 
ata  will  quickly  settle  the  doubts  in  such  a  case. 

Tlic  Kidney. — Abnormal  conditions  of  the  kidney  often 
simulate  ovarian  tumors,  especially  sarcomata,  hydrone- 
phrosis, or  pyonephrosis.  When  movable,  misplaced,  or 
single,  a  kidney  has  often  caused  great  difficulty  in  diagnosis. 

The  physical  signs  of  a  renal  tumor  are  very  character- 
istic. There  is  a  swelling  in  one  or  both  loins  which  yields 
a  dull  sound  on  percussion,  but,  as  the  colon  lies  in  front 
of  the  kidney,  an  area  of  resonance  is  usually  present  when 
it  is  percussed  from  the  front. 

T/ie  Spleen. — When  enlarged,  this  viscus  forms  a  tumor 
extending  from  the  left  hypochondrium  obliquely  down- 
ward to  the  umbilicus,  and  as  far  as  the  pelvis  when  very 
large.  It  gives  rise  to  dulness  on  percussion,  moves  up 
and  down  with  respiration,  lies  in  front  of  the  colon,  and 
presents  a  characteristic  notched  border. 

Occasionally  the  spleen  has  such  a  long  pedicle  that  it 
may  reach  every  region  of  the  abdomen  and  even  lodge 
on  the  floor  of  the  pelvis.  Such  "  wandering  "  spleens  are 
liable  to  twist  their  pedicles. 

Very  large  spleens  have  been  mistaken  for  ovarian  or 
uterine  tumors,  more  often  the  latter.  In  one  remarkable 
case  coeliotomy  was  performed,  and  a  tumor  supposed  to 
be  a  uterine  myoma  was  removed;  subsecjuently,  when  the 
fragments  were  examined  microscopicall)-,  the  tissue  was 
discovered  to  be  splenic  (Varneck). 

When  the  spleen  is  occupied  by  a  large  echinococcus 
colony,  then  the  resemblance  to  an  ovarian  cyst  is  very 
close. 

The  Liver. — When  the   li\cr  is  greatly  enlarged  it   has 
simulated  an  ovarian  tumor.     A  very  distended  gall-blad- 


DISEASES   OF   THE    OVARIES.  285 

der  may  simulate  a  renal  tumor,  cancer  of  the  pylorus,  or 
even  an  ovarian  cyst  with  a  long  pedicle.  But  a  very 
large  hydrocholecyst  has  been  known  to  reach  into  the 
hypogastrium. 

A  greatly  distended  stomach,  a  large  cyst  of  the  great 


Rectum.  Tumor  of  ovary.  Uterus. 


Fig.  93. — Large  fibrom.i  of  the  ovary  which  obstructed  labor  at  term  (Museum  Royal 
College  of  Surgeons). 

omentum  (omental  hydrocele),  chyle  cysts  of  the  mesen- 
tery, pancreatic  cyst,  and  echinococcus  colonies  in  relation 
with  any  abdominal  viscus  are  sometimes  sources  of  diffi- 
culty in  diagnosis,  but  they  rarely  complicate  the  differen- 
tial diagnosis  of  tumors  of  the  genital  organs. 

Ovarian  Tumors  and  Pregnancy. — Throughout  the 


286  DISEASES   OE   WOMEN. 

description  of  the  diagnosis  of  ovarian  tumors  considerable 
stress  has  been  laid  on  the  necessity  of  careful  discrimina- 
tion between  a  tumor  of  an  ovary  and  pregnancy.  It  is 
now  important  to  discuss  the  difficulty  and  dangers  when 
the  two  conditions  coexist  (Fig.  93). 

When  an  ovarian  tumor  complicates  pregnancy,  it  is  not 
too  much  to  state  that  the  life  of  the  woman  is  in  peril 
throughout  the  period,  and  the  danger  increases  with  each 
succeeding  month  of  gestation,  and  culminates  with  labor 
or  abortion. 

During  pregnancy  the  chief  dangers  to  be  apprehended 
are — 

(a)  Axial  rotation  of  the  tumor ; 

(b)  Rupture  of  the  cyst ; 

(c)  Incarceration  of  the  tumor  in  the  pelvis ; 

(d)  With  large  tumors,  impediment  to  respiration. 
When  the  tumor  is  not  interfered  with  and  pregnancy 

goes  to  term,  delivery  may  happen  easily  and  safely;  but 
in  many  cases  the  following  grave  complications  may 
occur: 

1.  When  the  tnvior  is  situated  above  the  uterus : 

(a)  Rupture  of  the  cyst; 

(b)  Axial  rotation ; 

(c)  Suppuration  of  the  cyst. 

2.  When  the  tumor  occupies  the  pelvis  it  offers  mechanical 
impediment  to  delivery.  The  fcvtus  invaiiably  dies  in  these 
circumstances. 

The  following  accidents  may  happen  : 

(a)  Rupture  of  the  cyst ; 

(b)  Rupture  of  the  uterus ; 

(c)  Rupture  of  the  vagina; 

(d)  Extrusion  of  the  tumor  through  the  anus. 

Treatment, 

The  treatment  of  ovarian  tumors,  including  in  this 
general   term   tumors    of  the   oophoron,  paroophoron,  and 


DISEASES   OF   THE    OVARIES.  28/ 

parovarium,  is  early  removal.  It  has  been  shown  by  an 
overwhelming  amount  of  evidence  that  the  earlier  these 
tumors  are  removed  the  more  likely  is  the  operation  to  be 
followed  by  success.  The  removal  of  an  uncomplicated 
ovarian  tumor,  by  a  surgeon  of  experience  in  abdominal 
operations,  is  the  safest  and  most  successful  major  operation 
in  surgery. 

Ovariotomy  has  been  successfully  performed  on  an  infant 
of  two  years  and  on  a  woman  of  ninety-four  years.  In 
girls  between  the  age  of  ten  and  fifteen  years  ovariotomy  is 
attended  with  great  success.  Even  suppurating  cysts  are 
removed  with  admirable   results. 

Mortality. — Speaking  generally,  the  deaths  from  ovariot- 
omy vary  from  5  to  lo  per  cent,  in  experienced  hands ;  now 
and  then  operators  get  a  run  of  20,  50,  or  even  100  cases 
without  a  death.  With  less  experienced  surgeons  the 
death-rate  will  vary  from   15   to  20  per  cent. 

Ovariotomy  during  Pregnancy. — Before  the  fourth  month 
of  pregnancy  ovariotomy  is  attended  with  an  exceedingly 
low  risk  to  life,  and  the  chances  of  disturbing  the  pregnancy 
are  small.  After  the  fourth  month  the  risk  of  abortion 
increases  with  each  month.  When  an  ovarian  tumor  is 
discovered  during  labor  or  abortion  and  it  impedes  delivery, 
ovariotomy  should  be  performed  without  delay.  If  it  offers 
no  obstacle  to  delivery  and  causes  no  dangerous  symptoms, 
it  may  remain  till  after  the  puerperium.  When  a  puerperal 
woman  known  to  possess  an  ovarian  tumor  exhibits  un- 
favorable symptoms,  ovariotomy  should  be  resorted  to  with- 
out delay. 


CHAPTER    XXXII. 

DISEASES  OK  THE   PELVIC    PERITONEUM  AND  CONNEC- 
TIVE  TISSUE. 

SEPTIC  INFECTION;  EPITHELIAL  INFEC- 
TION; HYDROPERITONEUM;  PELVIC  CEL- 
LULITIS AND  ABSCESS. 

The  pelvic  region  of  the  coelom  in  a  woman  differs  from 
that  of  a  man  in  that  the  peritoneum  Hning  it  is  more  com- 
plexly arranged  and  invests  more  organs ;  in  addition,  two 
mucous  canals — the  Fallopian  tubes — open  directly  into  it. 
The  frequency  of  peritonitis  in  women  is  out  of  all  propor- 
tion to  its  occurrence  in  men,  and  the  excessive  liability  of 
women  to  peritoneal  infections  is  almost  entirely  due  to  this 
curious  relationship  of  the  pelvic  portion  of  the  coelom  to 
the  Fallopian  tubes. 

I.  Septic  Infection. — In  dealing  with  salpingitis  it  was 
pointed  out  that  septic  affections  of  the  uterus,  whether 
arising  primarily  in  the  cavity  of  that  organ  or  extending 
to  it  from  the  vagina,  are  very  liable  to  implicate  the  Fal- 
lopian tubes.  In  a  fair  proportion  of  cases  the  inflammatory 
process  extends  beyond  the  tubes  and  directly  infects  the 
pelvic  peritoneum.  When  the  septic  matter  which  thus 
escapes  into  the  ccelom  is  very  virulent,  grave  disturbances 
are  set  up  and  death  may  ensue  in  a  few  days. 

It  was  mentioned  in  Chapter  XXIV.  that  in  a  large 
number  of  cases  salpingitis  is  a  result  of  septic  endometritis 
following  upon  abortion  or  delivery  at  term ;  it  is  important 
also  to  appreciate  the  fact  that  when  pelvic  peritonitis  occurs 
as  a  sequel  to  labor  it  is  in  very  many  cases  called  "puer- 
peral fever "   or  "  puerperal  peritonitis."     As  a  matter  of 

288 


DISEASES   OF   THE  PELVIC  PERITONEUM.  289 

fact,  observations  arc  by  no  means  vvantin^^  to  demonstrate 
that  in  many  cases  thus  chisscd  the  disaster  (causing  in  very 
many  cases  the  death  of  the  patient)  was  due  to  actual  con- 
veyance of  septic  matter  from  the  uterine  cavity  into  the 
recto-vaginal  pouch. 

Serous  Perimetritis. — The  essential  features  of  this  variety 
consist  in  a  collection  of  inflammatory  exudation  in  the 
recto-vaginal  fossa,  which  floats  up  the  adjacent  intestines 
and  omentum ;  these  become  matted  together  and  to  the 
uterus,  so  as  to  form  a  sort  of  spurious  roof  to  the  pelvis. 
Under  these  conditions  the  fluid  collected  in  the  pelvis  very 
closely  simulates  a  retro-uterine  cyst. 

When  inflammatory  exudation  collects  in  the  utero- 
vesical  pouch  and  becomes,  as  it  were,  encysted  by  the 
intestines,  the  condition  is  sometimes  called  "  anterior 
serous  perimetritis."  The  physical  signs  of  such  a  collec- 
tion of  fluid  have  so  deceived  some  surgeons  as  to  lead 
them  into  the  belief  that  they  had  to  deal  with  an  ovarian 
tumor. 

2.  i^pitlielial  Infection. — In  this  book  mention  has 
been  made  of  epithelial  infection  of  the  peritoneum,  and  it 
will  be  useful  to  briefly  summarize  our  knowledge  of  this 
condition.  It  occurs  in  connection  with  the  following  affec- 
tions : 

(a)  Papillomatous  cysts ; 

(b)  Ovarian  dermoids ; 

(c)  Cancer  of  uterus,  gall-bladder,   rectum,   and    sig- 

moid flexure. 
It  has  already  been  stated  that  when  papillomatous  cysts 
rupture  into  the  coelom  the  fluid  contents  of  the  cysts,  often 
heavily  charged  with  cells,  are  scattered  over  the  perito- 
neum :  it  naturally  follows  that  the  recto-vaginal  and  utero- 
vesical  fossae  become  inundated  with  fluid,  and  the  cells 
sink  to  the  lowest  parts  of  these  recesses.  In  many  cases 
the  cells  engraft  themselves  on  the  peritoneum  and  grow 
into  warts.    This  accounts,  in  cases  of  affection  of  this  kind, 

19 


290  DISEASES   OE   WOMEN. 

for  the  abundance  of  warts  on  the  pelvic  peritoneum  in  com- 
parison with  other  parts. 

Similar  changes  are  sometimes  associated  with  the  rup- 
ture of  ovarian  dermoids,  and  one  case  has  been  reported  in 
which  the  peritoneum  was  beset  with  small  tufts  of  hair 
secondary  to  an  ovarian  dermoid.  Several  cases  have  been 
carefully  observed  and  reported,  in  which  the  peritoneum 
has  been  dotted  with  minute  dermoids  secondaiy  to  the 
rupture  of  primary  ovarian  dermoids. 

In  Chapter  XXXIV.  it  will  be  shown  that  echinococcus 
colonies  sometimes  infect  the  peritoneum  in  a  similar 
manner.  The  condition  is  strongly  exemplified  when  the 
peritoneum  is  infected  with  cancer.  Any  one  who  has  had 
merely  a  moderate  experience  in  the  dead-house  must  have 
noticed  in  individuals  dying  from  cancer  of  the  uterus, 
colon,  or  gall-bladder  that  in  the  majority  of  instances  the 
peritoneum  is  free  from  deposits.  Yet  occasionally  a  case 
comes  under  observ^ation  in  which  the  peritoneum  is  crowded 
with  hundreds  of  minute  nodules.  In  such  cases  a  careful 
examination  of  the  tumor  will  reveal  the  existence  of  a  small 
process  of  the  cancer  which  has  perforated  its  serous  cover- 
ing. This  process  may  be  no  larger  than  a  split  pea,  yet  it 
is  sufficient  to  produce  hundreds  of  secondary  nodules  on 
the  peritoneum.  When  the  cancer  invol\-es  the  peritoneum, 
fluid  is  sure  to  be  exuded  (hydroperitoneum),  and  the  move- 
ment of  this  fluid  serves  as  an  excellent  means  of  dissemi- 
nating the  epithelial  cells  over  the  belly. 

3.  Hydroperitoneum. — This  may  be  defined  as  an 
accumulation  of  free  fluid  in  the  belly,  due  to  the  irrita- 
tion of  primary  or  secondaiy  tumors  of  the  abdominal 
viscera,  or  to  the  extension  of  tubal  disease,  especially  tu- 
berculosis, to  the  peritoneum. 

Fluid  effusion  in  the  belly  secondary  to  cardiac  or  renal 
disease  or  obstruction  to  the  portal  circulation  is  due  to 
passive  causes,  and  the  name  ascites  should  be  restricted  to 
it :  hydroperitoneum  depends  on  an  active  irritative  cause 


DISEASES   OF  THE   PELVIC  PERITOAEUM.  29 1 

and  is  met  with  in  the  following  pelvic  conditions :  Papil- 
lomatous cysts  of  the  ovaries  ;  ovarian  sarcomata ;  ovarian 
dermoids  with  burst  loculi;  occasionally  with  inflamed  ova- 
rian cysts  and  uterine  myomata  ;  tubercular  peritonitis  ;  mild 
forms  of  salpingitis ;  and  adenoma  of  the  Fallopian  tubes. 

In  the  greater  proportion  of  cases  hydroperitoneum 
causes  no  difficulty.  Scattered  nodules  in  the  omentum 
and  in  the  parietal  peritoneum  are  signs  rarely  misinterpreted. 
The  conditions  which  give  rise  to  difficulty  are  those  occur- 
ring in  women  about  mid-life  who  are  apparently  in  excel- 
lent health,  but  seek  advice  on  account  of  increase  in  the 
size  of  the  belly,  which  furnishes  on  physical  examination 
the  ordinary  signs  of  ascites ;  but  there  is  no  oedema  of  legs 
or  eyelids,  no  cardiac  disease,  urine  normal  in  quantity  and 
quality,  and  no  signs  of  liver  trouble.  On  careful  examina- 
tion of  the  abdomen  there  is  no  evidence  of  the  existence 
of  a  solid  tumor,  and  perhaps  on  vaginal  examination  only 
an  indefinite  resistance  is  made  out  on  each  side  of  the 
uterus.  In  such  conditions  the  fluid  increases  in  quantity 
very  rapidly  and  renders  interference  imperative. 

Treatment. — In  all  cases  where  there  is  reasonable  doubt 
as  to  the  cause  of  hydroperitoneum  it  is  a  wise  course  to 
place  the  patient  under  the  influence  of  an  anaesthetic  and 
make  a  small  incision  in  the  linea  alba  midway  between 
the  umbilicus  and  the  pubic  symphysis,  and,  after  allowing 
the  fluid  to  escape,  it  is  usually  easy  to  determine  the  cause 
of  the  hydroperitoneum.  In  many  cases  the  peritoneum, 
visceral  and  parietal,  is  found  dotted  with  a  multitude  of 
minute  secondary  nodules  ;  then  the  fluid  is  cautiously 
sponged  out  and  the  incision  closed.  Even  then  it  is  to 
the  patient's  advantage,  as  a  clear  diagnosis  is  ensured.  On 
the  other  hand,  and  by  no  means  infrequently,  a  peduncu- 
lated and  easily  removable  tumor  of  the  ovary,  uterus,  or 
Fallopian  tubes  is  found,  the  removal  of  which  is  accompa- 
nied by  a  rapid  convalescence  and  restoration  to  vigorous 
health. 


292  DISEASES   OE    WOMEN. 

It  is  also  important  to  remember  that  hydroperitoneum  is 
sometimes  comj)licateci  with  h)'<hr)thorax,  and  the  removal 
of  the  cause  of  the  ccclomic  effusion — ovarian,  uterine,  or 
tubal  tumor — is  sometimes  followed  by  rapid  absorption  of 
the  fluid  in  the  pleural  cavities. 

4.  Pelvic  Cellulitis  (Parametritis). — This  signifies  in- 
flammation of  tlie  connective  tissue  between  the  folds  of 
the  broad  ligament  (mesometrium). 

Causes. — It  is  usually  a  sequence  of  septic  changes  orig- 
inating in  the  cervical  canal  and  cavity  of  the  uterus  follow- 
ing abortion,  delivery  at  term,  especially  instrumental  deliv- 
ery, and  operation  on  the  uterus,  and  is  often  associated 
with  some  injury  opening  up  a  communication  between  the 
uterine  canal  or  vagina  and  the  connective-tissue  tract  of 
the  mesometrium ;  for  example,  a  deep  laceration  of  the 
cervix.     It  occasionally  complicates  salpingitis. 

Pathologically,  pelvic  cellulitis  does  not  differ  from  septic 
inflammation  of  connective  tissue  in  more  superficial  regions 
of  the  body.  The  change  consists  in  the  infiltration  of  the 
connective  tissue  of  the  mesometrium  with  inflammatory 
products,  and  the  effects  depend  upon  the  extent  of  tissue 
involved  and  the  nature  of  the  virus. 

The  infiltration  usually  involves  one  broad  ligament,  dis- 
places the  uterus,  and  at  the  same  time  fi.xes  it.  When  the 
left  broad  ligament  is  involved  the  exudation  may  surround 
the  rectum.  When  the  infiltration  is  veiy  extensive  it  ele- 
vates the  broad  ligament  above  the  level  of  the  true  pelvis, 
and  the  exudation  extends  into  the  subserous  tissue  of  the 
anterior  abdominal  wall.  Occasionally  it  infiltrates  the 
connective  tissue  in  the  cave  of  Retzius  and  forms  a 
rounded  swelling  immediately  above  the  pubes  :  in  a  small 
proportion  of  cases  the  exudation  extends  into  the  tissue 
between  the  cervix  uteri  and  bladder,  raises  up  the  perito- 
neum, and  obliterates  the  utero-vesical  pouch.  Such  exu- 
dations sometimes  give  rise  to  considerable  hypogastric 
swellings  and  cause  extreme  irritability  of  the  bladder. 


DISEASES   OF  THE   PELVIC  PERITONEUM.  293 

In  a  very  large  proportion  of  cases  the  exudation  sub- 
sides in  the  course  of  a  few  weeks  and  the  patient  recovers ; 
in  some  it  slowly  extends  into  the  subserous  tissue  and 
converts  the  belly-wall  into  a  firm  resisting  mass.  In  such 
cases  the  illness  may  be  prolonged  for  many  weeks  and 
even  months. 

In  a  certain  proportion  of  cases  suppuration  occurs,  re- 
sulting in  a  pelvic  abscess. 

The  common  forms  of  pelvic  cellulitis  are  rarely  mis- 
taken for  other  conditions,  and  should  there  be  any  doubt 
a  little  patience  will,  in  most  cases,  enable  a  correct  diag- 
nosis to  be  made,  for  rest  will  promote  absorption  of  the 
exudation. 

5.  Pelvic  Abscess. — This  term  signifies  a  collection  of 
pus  between-  the  layers  of  the  mesometrium.  Usually  it 
is  the  sequel  of  an  attack  of  pelvic  cellulitis,  but  it  is 
sometimes  due  to  the  presence  of  a  sequestered  extra- 
uterine foetus  (lithopaedion),  decomposing  blood-clot  due 
to  mesometric  rupture  of  a  gravid  tube,  echinococcus 
cyst,  or  pus  from  a  pericaecal  abscess  burrowjng  under 
the  peritoneum. 

The  pus  in  a  pelvic  abscess  points  and  escapes  in  one 
of  many  situations.  The  abscess  may  open  into  the  mucous 
canals  of  the  pelvis — rectum,  vagina,  or  even  the  bladder. 
It  may  point  in  the  groin,  immediately  above  or  below 
Poupart's  ligament ;  the  pus  will  sometimes  burrow  beneath 
the  fascia  lata  and  point  in  the  middle  of  the  thigh,  usually 
on  the  outer  side.  Occasionally  it  travels  by  the  side  of 
the  urachus  and  points  at  the  navel ;  exceptionally  it  will 
burrow  through  the  greater  sciatic  notch  and  gain  the 
buttock. 

Signs. — The  onset  of  pelvic  cellulitis  is  usually  marked 
by  a  rigor,  followed  by  pain  in  one  or  both  flanks ;  febrile 
symptoms  supervene,  and,  as  the  exudation  increases,  trou- 
bles during  micturition  or  defecation  are  experienced. 
These  signs  are  of  greater  significance  when  they  follow 


294  DISEASES   OF   WOMEN. 

within  twenty-four  or  thirty-six  hours  of  abortion,  dcHvery, 
or  operation  on  the  uterus. 

Diagnosis. — On  examining  through  the  vagina,  a  hard 
mass  will  be  found  occupying  one  or  both  hgaments ;  in 
many  cases  the  hard  masses  are  conjoined  by  a  ring  of 
hard  tissue  surrounding  the  neck  of  the  uterus.  Wlien  the 
whole  extent  of  the  ligaments  is  infiltrated  the  swelling  is 
perceptible  at  the  brim  of  the  pelvis  and  in  the  hypo- 
gastrium. 

When  suppuration  occurs,  the  temperature,  pulse,  and 
general  condition  of  the  patient  are  those  accompanying 
large  collections  of  pus.  The  local  signs  are — the  pre- 
viously hard  masses  become  softer,  fluctuation  is  detected, 
or  the  overlying  skin  is  oedematous  and  perhaps  red.  The 
abscess  is  then  said  to  point. 

The  pus  furnished  by  a  pelvic  abscess  is  often  intensely 
foetid ;  this  is  mainly  due  to  contamination  from  the  bowel. 
In  the  course  of  the  formation  of  the  abscess  the  peritoneum 
is  stripped  from  the  wall  of  the  rectum,  and  its  tissues,  be- 
coming softened,  allow  of  the  passage  of  intestinal  contents 
loaded  with  pathogenic  micro-organisms  into  the  exudation, 
and  putrefaction  is  established. 

Treatment. — In  the'  acute  stages  of  pelvic  cellulitis  the 
patient  is  confined  to  bed,  the  bowels  kept  regular  by  means 
of  saline  purgatives  ;  and  warm  vaginal  douches  should  be 
frequently  administered  by  a  careful  nurse.  Glycerin  tam- 
pons help  to  relieve  the  pelvic  congestion.  When  there  is 
much  abdominal  pain,  warm  fomentations  to  the  h)^pogas- 
trium  give  great  relief 

When  suppuration  occurs  and  the  pus  can  be  localized, 
an  incision  should  be  made  into  it  and  the  abscess  drained. 
It  is  preferable  to  evacuate  a  pelvic  abscess  through  the 
belly-wall  rather  than  by  an  incision  in  the  vagina.  Should 
the  abscess  burst  into  the  vagina,  the  aperture  of  commu- 
nication is  apt  to  close,  and  defective  drainage  leads  to 
reaccumulation  of  pus :    under   these   circumstances    it   is 


DISEASES   OF    THE   PELVIC  PERITONEUM.  295 

advisable  to  dilate  the  opcniiiLj  to  ensure  drainage.  When 
the  abscess  is  due  to  suppuration  of  a  gestation  sac  the 
sinus  should  be  enlarged,  and  all  fragments  of  bone  and 
other  foetal  tissues  removed. 

As  in  all  cases  of  prolonged  suppuration,  the  patient's 
strength  must  be  supported  by  nutritious  and  easily  digest- 
ible food ;  quinine  and  iron  preparations  are  useful,  and 
health  is  finally  restored  by  change  of  air. 


CHAPTER    XXXIII. 

DISEASES   OF  THE  PELVIC    PERITONEUM  AND   CONNEC- 
TIVE TISSUE  (Continued). 

TUMORS    OF    THE    MESOMETRIUM    (BROAD 
LIGAMENT). 

In  addition  to  tumors  of  the  ovary,  parovarium,  and 
Gartner's  duct,  others  sometimes  arise  from  the  round  liga- 
ment of  the  uterus,  the  ovarian  ligament,  as  well  as  from 
the  proper  tissues  of  the  mesometrium,  and  so  simulate 
ovarian  and  uterine  tumors  that  accurate  diagnosis  from 
physical  signs  is  impossible. 

It  will  be  convenient  to  describe  them  in  the  following 
order :    Lipomata,  myomata,  and  sarcomata. 

I/ipomata. — Under  normal  conditions  fat  is  sometimes 
seen  between  the  layers  of  the  mesometrium,  but  it  is 
rarely  met  with  in  the  neighborhood  of  the  Fallopian  tube. 

Occasionally  the  broad  ligament  is  occupied  by  a  fatty 
tumor  as  large  as  a  fist,  and  in  one  exceptional  case  a 
lipoma  reaching  as  high  as  the  navel  was  successfully  enu- 
cleated from  a  woman  thirty-two  years  of  age :  it  weighed 
5  kilogrammes  (Treves). 

Myomata. — Unstriped  muscle-fibre  apart  from  the  uterus 
and  Fallopian  tubes  exists  in  three  situations  in  the  meso- 
metrium:  (i)  in  the  round  ligament  of  the  uterus;  (2)  in 
the  ovarian  ligament ;  (3)  in  the  connective  tissue  between 
its  folds. 

(i)  The  Round  Ligament  of  the  Uterus. — Myomata  and 
fibromyomata  arising  in  this  structure  are  rare.  Several 
examples  have  been  recorded  in  connection  with  the  part 

296 


DISEASES   OF   THE  PELVIC  PERITONEUM.  297 

of  this  ligament  which  traverses  the  inguinal  canal.  They 
are  oval  in  shape  and  have  been  reported  as  big  as  cocoa- 
nuts. 

(2)  The  Ovarian  Ligament. — Myomata  of  this  structure 
have  been  observed  as  large  as  a  fist.  They  simulate  small 
ovarian  tumors  and  require  the  same  treatment — that  is, 
removal. 

(3)  Mesonietric  Myomata. — A  stratum  of  unstriped  mus- 
cle-fibre lies  immediately  beneath  the  peritoneum  forming 
the  mesometrium,  and  replaces  the  subserous  tissue  which 
exists  in  other  regions :  this  layer  of  muscle-fibre  is  directly 
continuous  with  the  muscle-tissue  of  the  uterus,  and  is  oc- 
casionally the  source  of  myomata  which  may  attain  large 
dimensions. 

Mesometric  myomata  are,  as  a  rule,  bilateral,  and  when 
of  moderate  size  they  are  mobile,  ovoid  in  shape,  and  easily 
enucleated.  After  a  time  they  grow  with  great  rapidity,  and 
may  in  a  few  months  attain  a  weight  of  ten  kilogrammes 
or  more.  As  the  tumor  rises  out  of  the  pelvis  it  carries  the 
uterus  and  its  appendages  with  it.  The  rapid  growth  and 
the  profound  way  these  large  tumors  sometimes  affect  the 
patient's  health  are  due  to  septic  infection  of  the  tumor. 
The  tissue  of  such  myomata  is  very  liable  to  become  myx- 
omatous, resulting  in  the  formation  of  large  cavities ;  calci- 
fication is  not  infrequent. 

Mesometric  myomata  occur  after  the  thirty-fifth  year- 
They  are  very  formidable  tumors  to  deal  with ;  the  best 
method  of  treating  them,  even  when  large,  is  enucleation. 
More  than  half  the  cases  succumb  if  operation  be  delayed 
until  the  tumor  rises  above  the  pelvic  brim. 

Sarcomata. — They  are  very  rare  in  the  mesometrium 
and  usually  consist  of  spindle-cells.  They  grow  very  rap- 
idly and  quickly  destroy  life. 

^chinococcus  Colonies  {Hydatids)  of  the  Pelvis. — 
In  connection  with  the  pelvis  it  will  be  necessai-)'  to  con- 
sider echinococcus    cysts  in  the  following  situations :    (a) 


298  DISEASES   OF   WOMEN. 

The  uterus;  (b)  The  niesometrium  ;  (c)  The  pelvic  bones; 
(d)  Tlie  omentum  ;  (e)  The   Fallopian  tubes. 

There  is  no  authentic  example  on  record  of  a  primary 
echinococcus  cyst  of  the  ovary. 

(a)  The  Uterus. — Echinococcus  cysts  have  on  several 
occasions  been  observed  growing  beneath  the  peritoneal 
investment  of  the  uterus  and  forming  a  tumor  as  large  as 
the  patient's  head. 

Clinically,  such  cysts  simulate  either  an  ovarian  tumor 
or  a  uterine  myoma.  When  the  cysts  contain  vesicles  there 
is  no  difficulty  in  determining  their  nature  in  the  course  of 
an  operation.  When  they  are  sterile  the  echinococcus 
origin  of  the  cyst  is  rarely  suspected. 

(b)  TJic  Mcsomctruivi. — Many  examples  of  echinococcus 
colonies  between  the  layers  of  the  broad  ligament  have 
been  reported.  As  a  rule,  they  form  part  of  a  general 
invasion  of  the  subperitoneal  tissue.  The  colonies  are  apt 
to  communicate  with  the  vagina,  bladder,  or  rectum,  and 
the  characteristic  vesicles  escape  with  the  urine  or  faeces. 
Such  communications  lead  to  septic  infection  of  the  cyst, 
and  suppuration,  with  all  its  evils,  is  the  consequence;  or 
sinuses  form  in  the  groin,  and  the  patient  sinks  exhausted 
from  long-maintained  suppuration. 

(c)  The  Bony  Pelvis. — Not  the  least  interesting  circum- 
stance in  connection  with  echinococcus  cysts  affecting  the 
pelvis  is  the  effect  they  produce  on  the  bones :  firm  osseous 
barriers  offer  little  resistance  to  the  invading  propensities 
of  echinococcus  cysts,  and  they  pass  from  the  ilium  into  the 
sacrum  irrespective  of  the  sacro-iliac  synchondrosis.  Hy- 
datids of  the  ilium  or  ischium  erode  the  walls  of  the  ace- 
tabulum and  overrun  the  hip-joint,  and  when  left  to  run 
their  course  unchecked  will  extend  into  the  head  of  the 
femur. 

(d)  The  OtneutuDi. — Large  echinococcus  colonies  in  the 
great  omentum  lodge  in  the  true  pelvis,  and  so  simulate  the 
physical  signs  of  ovarian  cysts  that  they  deceive  the  most 


DISEASES   OF   THE   PELVIC  PERITONEUM.  299 

careful  and  experienced  surgeon.  Occasionally  they  dip  so 
low  that  they  lodge  on  the  floor  of  tiic  pelvis  and  fill  the 
recto-vaginal  fossa.  Accurate  diagnosis  is  then  very  dif- 
ficult, indeed  almost  impossible. 

(e)  The  Fallopian  Tubes. — Very  exceptionally,  echinococ- 
cus  vesicles  have  been  found  in  the  Fallopian  tubes.  In  a  re- 
markable case  in  a  woman  thirty-two  years  of  age  (reported 
by  Doleris)  both  tubes  were  so  stuffed  with  vesicles  that 
they  formed  a  large  tumor  reaching  above  the  umbilicus. 
The  mass  weighed  2  kilogrammes,  and  consisted  of  the  two 
tubes  coiled  upon  themselves  like  small  intestines,  and  so 
elongated  that  one  measured  57  and  the  other  53  cm. 
The  tubes  were  successfully  removed.  Maloney  described 
the  case  of  a  girl  fourteen  years  of  age  whose  right  Fal- 
lopian tube  was  greatly  distended  and  thrown  into  convolu- 
tions by  a  mass  of  echinococcus  vesicles.  The  girl  had 
echinococcus  cysts  in  her  liver,  and  one  adherent  to  the 
fundus  of  the  uterus  had  communicated  with  the  Fallopian 
tube. 

Secondary  Peritoneal  Infection. — In  the  course  of  a  coeli- 
otomy  for  echinococcus  cysts  minute  cysts  and  nodules  are 
sometimes  seen  scattered  over  the  peritoneum,  particularly 
in  the  pelvic  region.  Many  of  these  nodules  show  the 
lamination  chara(?teristic  of  echinococcus  membrane,  and 
occasionally  booklets  will  be  detected.  This  condition  is 
due,  in  all  probability,  to  the  escape  of  fluid  from  an  echi- 
nococcus cyst,  in  consequence  either  of  rupture  or  of  leak- 
age during  tapping.  Brood-capsules  escape  with  the  fluid, 
and,  gravitating  to  the  recesses  of  the  pelvis,  engraft  them- 
selves on  the  peritoneum. 

Diagnosis. — The  clinical  recognition  of  echinococcus 
cysts  in  the  pelvic  organs,  mesometrium,  or  bones  is  some- 
times made  by  a  sort  of  "  lucky  guess  "  when  other  and 
more  common  diseases  can  with  certainty  be  excluded. 
Occasionally  when  a  patient  seeks  advice  for  pelvic  trouble, 
and  brings  "vesicles"  which  have  escaped  by  the  rectum. 


300  DISEASES   OE   WOMEN. 

vagina,  or  urethra,  much  speculation  is  spared.  When  the 
bones  are  eroded  and  swellings  form  under  the  skin,  they 
are  punctured  and  characteristic  fluid  with  vesicles  and 
hooklets  escapes,  and  so  the  diagnosis  is  established. 
When  the  cysts  suppurate  the  physical  signs  are  those  of 
abscess. 

Treatment. — When  the  cysts  take  the  form  of  peduncu- 
lated tumors,  either  of  the  omentum  or  uterus,  they  require 
the  same  treatment  as  ovarian  tumors — viz.  ligature  and 
removal.  When  sessile  or  when  their  false  capsules  are 
very  adherent,  enucleation  of  the  mother  cysts  is  a  very 
successful  measure. 

Should  the  cysts  burrow  in  the  mesometrium  and  open 
into  hollow  pelvic  viscera,  then  the  treatment  of  the  sup- 
purating cavities  and  sinuses  is  very  unsatisfactory^  and  is 
rarely  successful.  The  method  of  dealing  with  them 
should  be  on  the  same  principle  as  that  adopted  for  pelvic 
abscess.  The  course  of  the  case  is  very  protracted,  and 
death  usually  occurs  from  septic  complications. 


CHAPTER  XXXIV. 

DISORDERS   OF   MENSTRUATION. 

AMENORRHCEA;     MENORRHAGIA    AND    ME- 
TRORRHAGIA;   DYSMENORRHCEA. 

Amenorrhcea.— This  signifies  absence  of  menstruation 
between  puberty  and  the  menopause.  Considered  cHnic- 
ally,  it  is  of  three  kinds  : 

(i)  Primary  AvienorrJicea. — Although  the  patient  has 
passed  the  ordinary  age  of  puberty,  menstruation  has  never 
occurred. 

(2)  Secondary  Amenorrhoca. — Menstruation  is  suppressed 
after  having  once  been  estabhshed. 

(3)  Cryptomenorrhcea. — Menstruation  occurs,  but  its  prod- 
ucts are  retained  in  consequence  of  atresia  of  the  genital 
passages. 

Primary  AmenorrJicea. — The  physician  should  set  about 
his  inquiry  systematically.  Firstly :  Has  the  patient  never 
menstruated?  She  may  be  the  subject  of  congenital 
absence  or  of  arrest  of  development  of  the  uterus  or  its 
adnexa.  This  is  ascertained  by  a  recto-abdominal  examin- 
ation, with  the  assistance,  if  necessary,  of  an  anaesthetic. 
If  such  a  condition  be  found,  interference  is  obviously  use- 
less and  unnecessary.  If  the  organs  are  present  and  nor- 
mally developed,  the  case  may  be  one  simply  of  delayed 
puberty ;  there  are  instances  on  record  of  menstruation 
occurring  for  the  first  time  after  the  age  of  twenty,  the 
patient  being  otherwise  quite  healthy.  In  such  a  case 
interference  is  equally  contraindicated.  Attempts  to  estab- 
lish the  function  by  electricity,  massage,   drugs,  etc.  are  to 

301 


302  niSEASES   OE   WOMEN. 

be  deprecated  as  lonjr  as  the  j^cneral  health  is  good.  Even 
pregnancy  may  occur  before  the  appearance  of  the  menses. 
If,  on  the  other  hand,  a  constitutional  cause  of  amenorrhoea 
exists,  such  as  phthisis,  chlorosis,  or  cretinism,  this  should 
be  treated  on  general  principles  and  on  the  lines  laid  down 
below.  Many  patients  seek  advice  on  the  supposition  that 
the  amenorrhcea  is  the  cause  of  their  ill-health  or  is  in  itself 
detrimental.  This  idea  should  be  combated,  for  it  is  an 
advantage  rather  than  otherwise  to  an  anaemic  woman 
not  to  menstruate.  It  may  even  be  advisable  to  endeavor 
to  check  free  menstruation  in  cases  of  anaemia. 

Secondary  Amenorrhoea. — The  menses  are  suppressed 
after  having  been  previously  established.  That  amenorrhoea 
may  be  due  to  pregnancy  is  a  fact  that  must  be  always 
borne  in  mind,  even  in  the  case  of  unmarried  women  and 
whatever  their  station  in  life :  a  mistake  on  this  point  may 
lead  to  very  unpleasant  consequences.  The  practitioner 
should  therefore  be  on  the  alert,  especially  when  amenor- 
rhoea has  suddenly  supervened  in  a  healthy  woman  pre- 
viously regular.  There  will  be  usually  very  little  difficulty 
in  verifying  the  fact,  and  in  the  early  months  a  guarded 
opinion  should  be  given.  If  pregnancy  can  be  excluded, 
the  inquiry  into  the  cause  of  the  amenorrhoea  will  be  sim- 
plified. Suppression  of  the  menses  for  a  few  months  after 
the  first  onset  of  menstruation  occurs  not  infrequently 
in  perfectly  healthy  girls  ;  in  such  cases  we  may  look  for 
its  re-establishment  in  due  course  without  any  active 
measures. 

Premature  cessation  of  menstruation  sometimes  occurs : 
it  may  be  due  to  a  mental  shock  or  to  systemic  disease. 
When  there  has  been  no  such  cause  at  work,  these  patients 
often  give  a  history  of  relative  sterility ;  for  instance,  they 
have  borne  only  one  or  two  children  during  ten  or  fifteen 
years  of  married  life. 

Pathological  conditions  causing  amenorrhoea  are  local 
or  constitutional ;  among  the  former  may  be  enumerated 


DISORDERS   OF  MENSTRUATION.  303 

atrophy  of  the  ovaries  and  excessive  involution  of  the 
uterus.  The  most  common  constitutional  causes  are  an- 
jeniia  and  phthisis,  where  the  amenorrhcea  is  undoubtedly 
beneficent.  Acute  febrile  diseases  may  be  followed  by 
temporary  amenorrhoea,  and  the  same  result  follows  from 
a  cold  caught  during  menstruation  ;  the  popular  estimate 
of  the  harmful  results  of  getting  the  feet  wet  during  a 
period  is  supported  by  experience. 

Lastly,  certain  chronic  intoxications,  such  as  that  result- 
ing from  morphiomania,  have  the  same  effect. 

Cryptonicnorvliooa. — The  patient  experiences  a  monthly 
molimen,  but  "  sees  nothing."  This  is  not  infrequently  the 
precursor  of  the  onset  of  menstruation.  In  other  cases  we 
have  to  deal  with  the  retention  of  the  menses.  When  there 
is  occlusion  either  of  the  cervix  or  of  the  vagina  the  men- 
strual blood  accumulates  every  month,  and  gradually  pro- 
duces distention  of  the  vagina  or  uterus,  or  both.  Abdom- 
inal examination  then  reveals  a  pelvic  tumor  whose  size 
varies  with  the  duration  of  the  retention :  a  combined  recto- 
abdominal  examination  will  usually  place  the  diagnosis 
beyond  doubt,  especially  if  an  imperforate  hymen  is  also 
found.  Surgical  treatment  is  required  (see  p.  74).  Two 
points  should  be  remembered  in  this  connection:  firstly 
that  the  menstrual  molimen  may  occur  in  cases  of  congen- 
ital absence  of  the  uterus,  where  there  is  consequently  no 
retention  ;  and,  secondly,  that  retention  may  coexist  with 
the  appearance  of  the  menses  in  cases  of  double  uterus  or 
vagina. 

Treatment. — This  has  been  in  a  measure  indicated  in  the 
analysis  of  the  etiology  of  the  condition.  Imperfect  devel- 
opment, if  not  too  marked,  may  sometimes  be  remedied  by 
stimulative  treatment  in  the  direction  of  increasing  the  pel- 
vic circulation.  This  is  probably  the  modus  operandi  of 
most  emmenagogues  :  it  is  doubtful  whether  an\'  of  them 
has  a  specific  action  on  the  uterus.  They  should  be  given, 
if  possible,  just    before    the    time   of  an    expected   period. 


304  DISEASES   OE   WOMEN. 

Warm  foot-  or  hip-baths  will  often  assist  the  process  if 
aclniinisterecl  at  this   time. 

Phthisical  patients  should  be  treated  with  tonics  and  cod- 
liver  oil.  Anaemia  yields  readily,  as  a  rule,  to  iron,  which 
is  best  given  either  in  the  form  of  Blaud's  pills,  of  which 
nine  may  be  taken  daily  for  six  weeks,  or  in  a  saline  ape- 
rient mixture.  Constipation  is  a  constant  feature  of  amen- 
orrhoea  associated  with  anaemia,  and  saline  laxatives  should 
form  a  routine  part  of  the  treatment.  In  cases  of  simple 
anaemia  and  chlorosis,  so  common  among  shop-girls  and 
domestic  servants,  menstruation  will  almost  invariably  be 
speedily  re-established  as  the  anaemic  condition  improves. 

Amenorrhoea  is  not  infrequently  found  among  the  in- 
sane :  if  in  such  a  case  menstruation  comes  on  again,  the 
mental  condition  often  improves,  indicating,  not  that  the 
amenorrhcea  is  the  cause  of  the  insanity,  but  that  nutritive 
conditions,  which  were  probably  responsible  for  both  symp- 
toms, have  improved.  Return  of  menstruation  without 
mental  improvement  makes  the  prognosis  bad  as  regards 
the  insanity. 

Menorrhagia. — This  denotes  excessive  bleeding  at  the 
menstrual  periods,  and  is  a  relative  term.  What  is  an 
ordinary  menstrual  flow  in  one  woman  may  constitute  men- 
orrhagia  in  another.  Some  lose  more  in  three  days  than 
others  in  seven  or  eight.  So  the  loss  sustained  by  a  patient 
at  any  one  time  must  be  judged  of  in  relation  to  the  stand- 
ard of  her  habitual  menstruation-type. 

Metrorrhagia  means  a  discharge  of  blood  in  the  inter- 
vals of  menstruation.  Menorrhagia  passes  insensibly  into 
metrorrhagia,  and  the  two  conditions  may  be  considered 
together. 

An  abundant  menstrual  discharge  occurring  but  once 
and  limited  to  the  period  need  cause  no  anxiety.  Repeti- 
tion of  such  a  hemorrhage  or  its  prolongation  into  the 
intermenstrual  period  necessitates  a  careful  inquiry  into 
the  cause.     To  continue  to  treat  menorrhagia  with  drugs, 


D/SOKDfiRS   OF  MENSTRUATION.  305 

without  examination,  is  unpardonable  :  in  this  way,  especially 
at  the  ai^e  of  the  menopause,  uterine  cancer  has  frequently 
been  able  to  make  such  strides  and  ^ain  such  a  hold  that  a 
miserable  existence  and  a  speedy  death  have  been  the  only 
possibilities  left ;  while  in  other  cases  a  small  polypus,  whose 
removal  would  have  been  most  easy,  has  been  allowed  to 
blanch  a  woman  to  such  an  extent  that  months  or  years 
have  been  required  to  make  up  the  lost  ground. 

The  constitutional  causes  of  menorrhagia  are  purpura, 
scorbutus,  and  haemophilia.  Their  place  in  the  etiological 
list  is  unimportant,  on  account  of  their  rarity.  The  local 
causes  have  a  close  relation  to  the  age  and  sexual  history 
of  the  patient.     They  are  as  follows  : 

In  Virgins. — Below  the  age  of  twenty-five  the  most  com- 
mon cause  is  uterine  congestion,  which  in  turn  may  be  due 
to  exposure  or  cold  at  a  menstrual  period.  This  condition  is 
curable  by  rest  and  warmth.  From  the  age  of  twenty-five 
onward,  polypi  and  myomata  are  responsible  for  most  cases 
of  menorrhagia :  probably  the  hemorrhage  is  produced  in 
the  same  way  in  both  instances — viz.  by  the  increased  vas- 
cular condition  of  the  endometrium ;  for  we  often  find  large 
interstitial  or  subperitoneal  fibro-myomata  without  any 
menorrhagia  ;  but  it  is  very  rarely  that  we  meet  with  the 
submucous  variety  without  excessive  menstruation.  A 
small  polypus  may  lead  to  greater  hemorrhage  and  more 
excessive  blanching  than  any  other  condition.  The  small 
cause  here  seems  quite  inadequate  in  comparison  with  the 
magnitude  of  the  result.  The  treatment  is  obvious — dilata- 
tion of  the  cervix  and  removal  of  the  polypus. 

In  the  Married. — In  addition  to  the  above  conditions  we 
meet  with  others  to  which  in  many  cases  the  hemorrhage 
is  due.  Thus  we  often  hear  the  following  history :  A 
patient  states  that  she  was  in  good  health  till  she  had  a 
labor  or  a  miscarriage  some  months  or  years  previously, 
and  that  she  has  never  been  the  same  since.  Menorrhagia 
has  come  on,  with  or  without  metrorrhagia.  If  it  was  a 
20 


306  DISEASES   OF   WOMEN. 

miscarriage,  further  inquiry  often  elicits  the  information  that 
the  patient  was  up  and  about  two  days  after.  Examination 
usually  reveals  one  of  two  conditions :  {a)  The  utei-us  is 
enlarged  and  bulky ;  the  os  is  patulous,  and  through  it  pro- 
jects a  little  clot  or  shred  of  tissue.  Portions  of  placenta 
or  membranes  have  been  retained,  and  involution  has  been 
hindered.  At  or  near  the  time  of  the  menopause  this  con- 
dition is  especially  apt  to  be  overlooked,  because  the  short 
period  of  amenorrhcea,  followed  by  irregular  hemorrhage  in 
a  woman  who  has  not  borne  children  for  some  years,  is  in- 
terpreted by  the  patient,  and,  unfortunately,  too  often  by  her 
doctor,  as  meaning  simply  "  the  change  of  life."  The  proper 
treatment  is  to  remove  the  remains  of  gestation,  dilating  the 
cervix  if  necessary. 

{6)  The  cervix  is  found  torn  and  its  mucous  membrane 
everted  and  eroded.  The  endometrium  is  hyperaesthetic, 
covered  with  fungous  granulations,  and  bleeds  readily.  Peri- 
metritic tenderness  may  be  also  present,  in  which  case  the 
uterus  is  more  or  less  fixed.  Attention  should  first  be 
directed  to  the  inflammatory  condition  :  when  this  has  sub- 
sided the  cavity  should  be  curetted  and  the  cer\'ix  repaired 
if  necessary  (see  Curetting  and  Trachelorrhaphy). 

From  the  age  of  thirty-five  onward,  cancer  of  the  uterus 
must  always  be  thought  of  as  a  possible  cause  of  hemor- 
rhage :  unmarried  women  are  not  exempt  from  it,  but  it 
is  much  more  common  among  those  who  have  borne 
children. 

On  the  subject  of  treatment  little  more  need  be  said. 
The  local  measures  above  indicated  arc  the  most  important ; 
to  these  should  be  added  rest  in  bed  when  the  hemorrhage 
is  at  all  severe.  Hydrastis,  viburnum,  ergot,  cannabis 
indica,  hyoscyamus,  and  hazcline  are  useful  as  accessories; 
as  sole  treatment  they  cannot  be  relied  on. 

Dysmenorrhcea. — This  means  "  painful  menstruation," 
but  we  must  quaiif}'  our  definition,  for  60  to  70  per  cent,  of 
women  suffer  pain  during  menstruation,  but  we  cannot  say 


DISORDERS   OF  MENSTRUATION.  307 

that  we  have  to  do  with  dysmenorrhoea  in  this  proportion 
of  cases.  Further,  the  intensity  of  pain  does  not  depend 
solely  on  the  nature  of  the  processes  occurring  peripherally 
in  the  generative  organs,  but  rather  on  the  relation  between 
this  factor  and  another — to  wit,  the  central  receptivity — so 
that,  given  the  same  pelvic  conditions  in  two  women,  the 
nervous  sensitiveness  of  one  may  lead  to  dysmenorrhoea, 
while  the  nervous 'stability  of  the  other  may  allow  the  pe- 
riod to  occur  with  very  little  disturbance.  Recognition  of 
this  fact  clinically  will  make  easier  both  the  interpretation 
and  the  treatment  of  the  phenomena  of  painful  menstruation. 

It  is  generally  thought  that  dysmenorrhoea  is  associated 
with  scanty  menstruation ;  the  reverse  is  more  often  true. 
To  understand  the  matter  we  must  not,  however,  be  content 
with  generalizations.  Painful  and  profuse  menstruation  is 
generally  associated  with  great  congestion  before  the  flow 
begins,  and  the  pain  occurs  during  this  congestive  period ; 
the  commencement  of  the  flow  is  then  accompanied  by  a 
feeling  of  relief  When  menstruation  is  painful  and  scanty 
the  pain  more  often  occurs  during  the  flow  and  has  its  origin 
in  painful  uterine  contractions.  The  situation  of  the  pain 
has  also  its  significance  :  when  this  is  in  the  back  the  cervix 
is  generally  at  fault,  whilst  pain  referred  to  the  umbilicus  is 
related  to  disturbance  in  the  body  of  the  uterus,  and  es- 
pecially in  the  fundus.  Pain  in  the  iliac  fossae  is  connected 
with  ox-arian  irritation,  and  shooting  pains  in  the  thighs  are 
often  due  to  a  subacute  inflammatory  condition  of  the  pelvic 
connective  tissue.  Further,  we  may  have  reflected  pains 
elsewhere,  the  most  frequent  being  in  the  breasts.  The 
constitutional  origin  of  dysmenorrhoea  is  illustrated  in  the 
case  of  girls  who  suffer  greatly  when  in  London,  but  who 
menstruate  painlessly  when  in  the  country. 

I.  DysDicnorrJuva  of  Constitutional  Origin. — This  must  be 
thought  of,  first,  in  dealing  with  girls  and  unmarried  women, 
for  obvious  reasons.  We  meet  with  two  well-defined  types  : 
the  first  is  the  neurotic.     Menstruation  has  often  been  pain- 


308  DISEASES   OF   WOMEN. 

ful  from  the  beginning,  and  the  flf)w  is  <;c'ncrally  scanty. 
The  organs  arc  normal  in  many  instances,  and  the  most 
careful  examination  leads  to  no  other  conclusion  than  that 
the  nervous  system  is  unduly  sensitive  and  unstable.  In 
other  cases  the  uterus  is  under-develo[)ed.  This  type  is 
the  one  met  with  so  often  among  girls  whose  physical  edu- 
cation has  been  neglected,  and  who  have  passed  most  of 
their  time  in-doors,  either  in  lu.xurious  indolence  or  in  over- 
study.  It  is  but  rarely  seen  among  the  working  classes, 
but  is  found  among  school-teachers  and  sometimes  among 
servants.  The  remedy  lies  in  improved  hygienic  conditions, 
more  exercise,  plain  food,  early  hours,  regularity  of  habits, 
with  a  definite  occupation  in  some  cases  and  restricted 
mental  work  in  others.  The  second  type  is  that  of  malnu- 
trition. Here  we  often  find  that  at  its  onset  menstruation 
was  painless.  Anjemia  and  con.stipation,  with  their  atten- 
dant train  of  symptoms,  are  common,  and  dysmenorrlujea 
alternates  with  periods  of  amenorrhcea.  The  same  altera- 
tion in  the  routine  of  daily  life  must  be  secured  as  in  the 
first  type,  with  the  addition,  where  necessar>^,  of  iron  tonics 
and  mild  aperients.  Nerve  sedatives  may  be  used  in  both 
cases  before  the  period,  especially  chloral,  hyoscyamus,  and 
belladonna,  but  they  must  be  given  with  discretion. 

Not  too  much  reliance  must  be  placed  on  the  constitu- 
tional treatment  of  .dysmenorrhoea.  It  has  its  place,  but 
will  also  often  disappoint.  While  it  should  be  persevered 
in  patiently  when  no  local  cause  for  the  dysmenorrhcca 
exists,  it  should  not  be  tried  too  long  before  making  an 
examination.  For  it  must  be  remembered  that  a  rectal 
examination  will  often  give  the  information  we  want ;  and 
it  is  better  in  certain  cases  to  make  a  vaginal  examination 
under  an  anaesthetic  than  to  go  on  working  in  the  dark. 

II.  DysnicnorrJiica  of  Local  Origin. — This  is  the  most 
common  kind  of  dysmenorrhoea,  and  the  following  causal 
conditions  are  met  with  : 

Faults  of  Confonnatio/i. — An  imperfectly-developed  uterus 


DISORDERS   OF  MENSTRUATION.  309 

is  often  associated  with  dysmenorrha^a,  but  the  nature  of 
the  relation  is  by  no  means  clear. 

Stenosis  of  the  os  internum,  other  than  congenital,  is  of 
two  kinds — anatomical  and  physiological.  The  first  is  due 
to  cicatrization  or  fibroid  induration,  the  second  to  spasm. 
Probably  both  varieties  act  in  the  same  way,  by  rendering 
the  uterine  contractions  painful.  The  pain  in  these  cases  is 
always  referred  to  the  back,  and  is  allied  in  character  to 
labor-pains.  It  is  seldom  that  the  sound  will  not  pass  into 
the  cervical  canal,  but  it  may  not  be  possible  to  introduce 
it  past  the  internal  os  without  an  anaesthetic.  If  it  does  so 
pass,  the  patient  complains  of  sudden  pain  in  the  back, 
which  she  will  often  state  to  be  just  like  her  menstrual  pain. 
Probably  the  passage  of  the  sound  induces  reflex  spasm, 
which  causes  the  pain.  It  should  be  remembered  that  the 
true  test  of  narrowing  is  difficulty  in  withdrawing  the  sound  ; 
difficulty  in  introducing  it  may  be  due  to  other  causes,  such 
as  tortuosity  or  sharp  curving  of  the  canal,  or  want  of  skill 
on  the  part  of  the  operator. 

The  proper  treatment  is  dilatation  of  the  cervical  canal 
under  an  anaesthetic  during  an  intermenstrual  period.  It  is 
a  good  plan,  in  cases  of  persistently  recurring  muscular 
spasm,  to  nick  the  margins  of  the  internal  os  in  one  or  two 
places  with  a  fine  bistoury. 

Fmilts  of  Positioji. — Both  versions  and  flexions  may  give 
rise  to  dysmenorrhoea,  as  described  in  Chapter  XIV.  In 
the  former  the  pain  is  due  mainly  to  congestion ;  in  the 
latter  it  is  probably  produced  in  the  same  way  as  in  cases 
of  stenosis — viz.  by  the  occurrence  of  painful  contractions. 
The  condition  finds  a  parallel  in  the  dystocia  due  to  falling 
forward  of  the  uterus  in  cases  of  pendulous  abdomen. 
Many  women,  however,  menstruate  painlessly  in  whom  the 
uterus  is  markedly  flexed ;  so  the  cause  is  probably  com- 
plex. It  is  a  matter  of  common  experience  that  dysmen- 
orrhoea associated  with  uterine  flexion  is  often  found  in 
nervous  women.     But,  whatever  explanation  we  adopt,  the 


3IO  DISEASES   OF   WOMEN. 

fact  remains  that  correction  of  a  flexion  is  followed  by 
relief  of  the  menstrual  pain  in  a  certain  proportion  of  cases. 
This  method  of  treatment  should  therefore  be  tried;  for 
details  see  the  section  on  Flexions  and  Displacements  of 
the  Uterus. 

Piivic  I)iJlaiinnatio)i. — This  is  a  fruitful  cause  of  dysmcn- 
orrhoea,  especially  in  women  who  have  borne  children.  It 
may  be  peri-uterine  or  intra-uterinc.  In  the  former  the 
uterus  is  fixed  in  the  midst  of  the  inflammatory  mass,  and 
the  extra  conj^estion  at  the  menstrual  periods  and  the 
hampered  uterine  contractions  are  alike  sources  of  pain. 
The  history  and  the  condition  found  on  examination  will 
readily  lead  to  a  correct  diagnosis.  Dysmenorrhcea,  it 
must  be  observed,  is  not  usually  a  marked  feature  in  pelvic 
inflammation,  and  probably  the  patient  will  seek  advice  on 
other  grounds ;  but  when  it  is  the  prominent  symptom,  the 
result  of  treating  the  inflammation  is,  as  a  rule,  highly  sat- 
isfactory. We  cannot  here  enter  into  the  subject  in  detail, 
but  the  broad  lines  of  treatment  are  rest  in  bed,  hot  xaginal 
douching,  fomentations  to  the  abdomen,  purgatives,  and 
occasional  glycerin  tampons. 

Intra-uterine  inflammation  as  a  cause  of  dysmenorrhcea 
is  easy  to  explain.  The  mucous  membrane  of  the  uterus 
becomes  very  sensitive  when  inflamed  ;  the  menstrual  con- 
gestion causes  pressure  on  the  nerve-endings ;  and  the 
same  effect  is  produced  when  the  uterine  contractions  press 
the  inflamed  surfaces  together.  The  treatment  is  that  of 
the  causal  pathological  condition. 

Membranous  Dysmenorrhcea. — This  signifies  painful 
menstruation  accompanied  by  the  discharge  of  membrane 
from  the  uterus. 

Causes. — The  literature  relating  to  the  causes  of  mem- 
branous dysmenorrhcea  is  very  great,  actual  facts  are  few 
and  relatively  unimportant,  conjectural  causes  abundant, 
positive  knowledge  practically  ////. 

Signs. — In  typical  cases  the  patient  during  the  menstrual 


DISORDERS   OF  MENSTRUATION.  3II 

period  passes  a  membranous  cast  of  the  uterine  cavity, 
sometimes  entire,  more  frequently  in  two  or  more  pieces. 

When  complete,  a  menstrual  decidua  is  a  bag  in  outline 
like  an  isosceles  triangle,  the  base  corresponding  to  the 
fundus  of  the  uterus ;  at  each  angle  there  is  an  opening, 
to  correspond  to  the  uterine  ostia  of  the  Fallopian  tubes, 
and  the  apical  opening  to  the  internal  orifice  of  the  cervical 
canal.  Menstrual  decidual  rarely  exceed  2  or  3  cm.  in 
length,  and  are  scarcely  2  mm.  in  thickness.  The  inner 
surface  is  smooth  and  dotted  with  minute  pits,  orifices  of 
the  uterine  glands.  The  outer  surface  is  shaggy.  The 
histology  is  like  that  of  the  decidua  of  pregnancy. 

The  patient  complains  at  the  beginning  of  the  flow  of 
pain,  intermitting  in  character,  which  gradually  increases 
until  the  membrane  is  expelled ;  then  the  pain  usually 
ceases.  The  membrane  is  discharged  usually  before  the 
end  of  forty-eight  hours  after  the  onset  of  the  menstrual 
period. 

Diagnosis. — Membranous  dysmenorrhoea  must  not  be 
confounded  with  the  decidua  discharged  from  a  case  of 
tubal  pregnancy  or  from  the  unimpregnated  horn  of  a 
bicorned  uterus  when  its  companion  cornu  is  gravid,  or  the 
membranes  in  a  case  of  early  abortion. 

"  No  case  can  be  regarded  as  one  of  membranous  dys- 
menorrhcea  unless  membranes  are  discharged  regularly, 
at  regular  monthly  periods,  and  for  a  considerable  time  " 
(Champneys). 

Treatment. — Drugs  are  useless ;  pregnancy,  even  when  it 
goes  to  full  time,  does  not  cure  the  condition.  Dilatation 
of  the  uterine  cavity  and  curetting  afford  temporary  relief. 


CHAPTER    XXXV. 

VAGINISMUS   AND    DYSl'ARKUNIA ;    STERILITY. 

Vaginismus. — This  term  is  applied  to  painful  reflex 
contractions  of  the  muscles  surrounding  the  vaginal  orifice 
when  attempts  are  made  to  effect  coitus.  The  muscles 
chiefly  at  fault  are  the  levators  of  the  anus. 

Causes. —  I.  It  occurs  in  the  newly  married  owing  to 
rigidity  of  the  hymen,  to  smallness  of  the  vaginal  orifice, 
to  an  inflammatory  condition  of  the  hymen  or  carunculne 
myrtiformes,  or  to  hypera^sthesia.  The  latter  may  be  the 
result  of  mere  nervousness  or  of  hysteria ;  and  vaginismu.s 
from  such  causes  may  persist  for  months  or  years  after 
marriage,  and  lead  to  much  domestic  unhappiness. 

2.  It  may  be  due  to  vulvitis  or  vaginitis  ;  to  ulcers,  sores, 
or  excoriations  about  the  vulva ;  to  inflamed  Bartholinian 
glands;  to  urethritis  or  urethral  caruncle.  Piles  will  often 
provoke  painful  contractions  of  the  levators  of  the  anus 
during  copulation. 

3.  It  occurs  in  later  life  in  connection  with  kraurosis 
vulvae,  the  nerve-endings  in  the  vulva  being  rendered  un- 
duly sensitive  by  subcutaneous  cicatricial  contraction. 

Dyspareunia  should  be  read  in  association  with  this 
section. 

Treatment. — The  first  essential  is  to  discover  the  anatomi- 
cal cause,  if  one  exists ;  otherwise  time  and  effort  may  be 
wasted  in  the  adoption  of  constitutional  treatment,  when  a 
simple  local  application  may  effect  an  immediate  cure. 
Thus,  in  all  inflammatory  conditions,  these  must  be  treated 

312 


VAGINISMUS  AND  DYSPARF.UNIA  ;   STERILITY.     313 

by  the  methods  described  under  their  respective  headings, 
and  temporary  sexual  abstinence  must  be  enjoined.  When 
the  vaginal  orifice  is  small,  the  use  of  simple  lubricants  such 
as  vaseline  may  suffice ;  if  not,  it  must  be  dilated  with  the 
fingers  or  with  dilators,  perferably  under  an  anaesthetic  ;  a 
series  of  Fergusson's  specula  often  answers  very  well.  A 
rigid  hymen  should  be  incised,  and  a  sensitive  one  excised. 
Simple  vaginal  hypera:sthesia  may  be  relieved  by  a  vaginal 
pessary  containing  half  a  grain  to  one  grain  of  cocaine,  and 
made  up  with  cacao  butter ;  this  is  inserted  ten  to  fifteen 
minutes  before  intercourse.  Hyperjesthesia  is  also  often 
improved  by  dilation  under  an  anaesthetic.  Caruncles  and 
cysts  must  be  removed.  Vaginismus  due  to  kraurosis 
must  be  treated  by  anaesthetic  local  applications,  such  as 
carbolic  acid,  cocaine,  or  menthol ;  or  by  dissection,  as  de- 
scribed under  Kraurosis. 

In  the  case  of  hysterical  or  nervous  women,  constitu- 
tional remedies  may  be  required,  including  sedatives  such 
as  bromides  or  hyoscyamus. 

It  must  be  remembered,  however,  that  the  cases  where 
no  local  treatment  is  available  are  very  rare,  and  include 
cases  of  "  incompatibility  "  which  are  beyond  the  reach  of 
medical  intervention. 

Dyspareunia. — This  signifies  pain  during  sexual  inter- 
course ;  it  may  exist  without  vaginismus — that  is,  without 
reflex  contraction  of  the  vaginal  orifice.  The  causes  of 
dyspareunia  are  much  the  same  as  those  of  vaginismus, 
and  may  be  classified  as  follows : 

1.  Psychical  causes,  as  mere  incompatibility  or  aversion 
when  the  marriage  is  unsuitable  ;  nervousness  ;  or  viaiivaise 

JlOHtC. 

2.  A)iatomical  Causes. — (a)  Smallness  of  the  vulva  and 
vagina,  congenital  and  due  to  under-development ;  or  ac- 
quired, as  the  result  of  cicatricial  contraction  or  kraurosis 
vulvae. 

(b)  Inflammatory  conditions  of  .the  vulva  or  vagina. 


314  DISEASES   OE   WOMEN. 

(c)  More  deep-seated  conditions,  as  prolapse  of  the 
ovaries  and  pelvic  inflammation. 

Sterility. — With  causes  of  sterihty  affectin^^  the  man  we 
have  not  here  to  do,  but  they  must  never  be  lost  si^ht  of 
in  investigating  a  case.  Yox  the  want  of  carefully-directed 
inquiry,  the  woman  has  not  infrequently  been  erroneously 
held  responsible  for  a  childless  marriage. 

In  considering  sterility  as  it  concerns  women,  we  must 
draw  a  broad  distinction  between — 

(A)  Conditions  which  do  not  allow  of  conception. 

(B)  Conditions  which  do  allow  of  conception,  but  which 
do  not  allow  of  development. 

(A)  Conditions  ivhich  do  not  allow  of  Conception. — (i) 
Age. — Save  under  exceptional  circumstances  conception 
does  not  occur  before  puberty.  After  this  age  fertility  gen- 
erally increases,  attains  its  maximum  at  about  the  age  of 
twent)'-five,  and  then  declines.  Thus  Matthews  Duncan 
gives  the  following  figures  as  the  result  of  the  analysis  of 
4447  cases : 

Age  at  marriage : 

15-19;  20-24;  25-29;  30-34;  35-39;  40-44;  45-49;  50.  etc. 
Percentage  sterile : 

7.3;      o.— ;      27.7;      37.5;      53.2;      90.9;      95.6;   100. 

That  is,  in  proportion  as  marriage  is  deferred  the  probabil- 
ity of  sterility  is  increased.  After  the  age  of  forty  the 
chances  of  childbearing  are  remote. 

The  following  laws,  which  Matthews  Duncan  enunciates, 
are  also  worth  bearing  in  mind  : 

The  question  of  a  woman's  being  probably  sterile  is 
decided  in  three  years  of  married  life. 

When  the  expectation  of  fertility  is  greatest  the  question 
of  probable  sterilit}'  is  soonest  decided,  and  vice  versa. 

Relative  sterility  will  arrive  after  a  shorter  time  according 
as  the  age  at  marriage  is  greater.  A  wife  who,  ha\ing  had 
children,  has  ceased  for  three  years  to  exhibit  fertility  has 


VAGINISMUS  AND  DYSPAREUNIA ;   STERILITY.     315 

probably  become  relatively  sterile — that  is,  will  probably 
bear  no  more  children — and  the  probability  increases  as 
time  elapses. 

(2)  Deficient  Oindation. — When  the  ovaries  are  under- 
developed sterility  is  absolute.  The  atrophy  which  they 
undergo  as  time  goes  on  has  the  same  effect,  and  to  this 
may  be  attributed  the  increasing  sterility  as  the  age  of  mar- 
riage is  postponed.  Ovarian  disease,  such  as  solid  tumors 
and  cysts,  also  leads  to  sterility.  These  conditions  may 
generally  be  diagnosed  by  careful  bimanual  examination. 
Delay  or  absence  of  menstruation  cannot  be  regarded  as  an 
absolute  indication  of  sterility. 

(3)  Deficient  Uterine  CJianges. — When  the  uterus  is  very 
small  and  menstruation  absent  or  scanty,  sterility  nearly 
always  results.  This  may  be  in  some  cases  due  to  the 
concomitant  deficiency  of  ovulation ;  in  others  to  the  in- 
ability of  the  uterus  to  prepare  for  an  oosperm  (fertilized 
ovum). 

(4)  I)icomplete  Sexnal  Intercourse. — This  may  be  due  to 
narrowness  of  the  vagina  or  to  a  rigid  hymen.  It  must  be 
remembered,  however,  that  conception  may  occur  when 
penetration  has  never  taken  place. 

(5)  Mechanical  Obstacles  to  Impregnation. — Under  this 
head  are  included  all  cases  of  atresia,  whether  of  the  vagina, 
of  the  internal  or  external  os  of  the  uterus,  or  of  the  Fallopian 
tube.  The  latter  frequently  becomes  sealed  up  at  its  fim- 
briated extremity,  as  the  result  of  pyosalpinx  ;  uterine  atre- 
sia may  also  be  due  to  disease,  but  congenital  atresia  is 
probably  more  common.  Vaginal  atresia  is  nearly  always 
congenital.  The  mechanical  obstacle  may  consist  not  in 
atresia,  but  in  want  of  adaptation  ;  as,  for  example,  in  cases 
where  the  cervix  is  pointed  markedly  forward,  either  from 
retroversion  or  from  anteflexion.  The  spermatozoa,  which, 
as  the  result  of  intercourse,  come  to  lie  principally  in  the 
posterior  vaginal  fornix,  are  then  unable  to  make  their  wa}' 
through  the  os  externum,  which  is  turned  away  from  them. 


3l6  DISEASES   OF   WOMEN. 

Polypi  and  other  tumors  in  tlic  genital  passages  may  also 
be  the  cause  of  sterility. 

(6)  Noxious  Discharges. — Septic  and  gonorrhoeal  dis- 
charges are  injurious  to  the  vitality  of  spermatozoa,  and  to 
this  cause  is  probably  partly  due  the  sterility  which  is  found 
in  cases  of  gonorrhoea,  endometritis,  and  adenomatous  dis- 
ease of  the  cervix.  Gonorrhoea  has  perhaps  an  even  more 
considerable  effect  in  the  changes  which  it  induces  in  the 
Fallopian  tubes.  Strong  antiseptic  and  frequent  simple 
vaginal  douches  also  prevent  conception. 

(B)  Conditions  ivhicJi  alUnv  of  Conception,  but  ivliicli  do 
not  allow  of  Development  of  the  Oosperm. — Under  this  head- 
ing are  included,  first,  the  as  yet  obscure  conditions  which 
lead  to  extra-uterine  gestation  ;  and  secondly,  pathological 
conditions  of  the  uterus  which  cause  earl}'  abortion,  such 
as  disease  of  the  endometrium  and  acute  flexions  of  the 
uterus. 

Treatjnoit  of  Sterility. — It  is  most  important  that  the 
practitioner  should  first  ascertain  whether  the  cause  of  ster- 
ility is  remediable  or  not,  for  nothing  leads  to  greater  dis- 
appointment of  the  patient,  and,  as  we  may  add,  to  greater 
discredit  to  her  attendant,  than  the  confident  holding  out 
of  a  hope  which  is  doomed  to  non-fulfilment.  Therefore 
the  development  of  the  uterus  and  ovaries  should  be  first 
investigated :  if  under-developed,  treatment  is  useless  and 
no  hope  should  be  held  out. 

In  cases  of  atresia  the  obstacle  may  often  be  overcome, 
as  by  division  of  a  vaginal  septum  or  by  uterine  dilatation. 
Correction  of  a  malposition  of  the  cervix  will  often  be  fol- 
lowed at  once  by  conception. 

Inflammatory  conditions  of  the  uterus  give  a  fair  pros- 
pect of  a  favorable  issue  as  the  result  of  appropriate  treat- 
ment, whether  they  have  acted  by  preventing  conception  or 
by  leading  to  early  abortion.  The  same  cannot,  however, 
be  said  of  tubal  disease,  where  the  prognosis  is  bad.  But 
treatment  should  nevertheless  be  undertaken  on  conserva- 


VAGINISMUS  AND   DYSPAREUNIA  ;    SIKKIUTY.     317 

tivc  lines.  Similarly,  polypi  and  other  tumors  should  be 
removed,  preserving  the  integrity  of  the  uterus. 

Harmful  discharges  will  be  removed  by  the  treatment 
of  the  uterine  or  vaginal  conditions  which  cause  them. 

Lastly,  the  conditions  of  intercourse  must  be  inquired 
into  and  the  patient  advised  accordingly. 

Sterility  due  to  psychical  causes  is  probably  irremediable 
in  most  cases,  but  moral  treatment  is  most  likely  to  suc- 
ceed. Here  the  judicious  husband  will  probably  be  a  better 
physician  than  the  medical  attendant. 


CHAPTER    XXXVI. 
DIAGNOSIS. 

Accurate  diagnosis  depends  upon  a  systematic  method 
of  inquiry  into  symptoms  and  e.xamination  of  physical 
signs.  We  shall  here  give  an  outline  of  the  way  such 
inquiry  and  examination  should  be  set  about. 

The  anamnesis,  or  account  obtained  by  questioning 
the  patient.  The  age,  occupation,  and  civil  condition  should 
be  first  noted  as  a  matter  of  routine,  for  these  points  may 
influence  subsequent  inquiries.  We  may  tiien  proceed  in 
the  following  order: 

(a)  Family  History. — The  present  health  or  cause  of 
death  of  the  nearest  relations  should  be  noted.  A  clue 
may  thus  be  gained  as  to  the  probability  of  tuberculosis, 
syphilis,  or  neuroses  in  the  patient's   case. 

(b)  Previous  Health. — Inquire  concerning  exanthemata 
or  rheumatic  fe\er  in  childhood,  anaemia  after  puberty, 
syphilis  or  gonorrhcea  after  marriage,  and  previous  treat- 
ment for  disease  of  the  pelvic  organs.  Thus,  a  history  of 
gonorrhoea,  followed  by  repeated  attacks  of  pelvic  inflam- 
mation, will  lead  one  to  suspect  tubal  mischief,  and  ft  may 
explain  the  presence  of  vaginitis,  endometritis,  or  a  Bar- 
tholinian  abscess ;  tuberculosis  may  lead  to  the  diagnosis 
of  tubercular  peritonitis  from  other  abdominal  swellings 
or  of  tubercular  salpingitis  when  the  tubes  are  affected  ; 
it  may  also  clear  up  the  nature  of  vulvar  cutaneous  affec- 
tions. A  history  of  operative  treatment  for  dysmenorrhoea 
will  prepare  for  the  finding  of  congenital  smallness  or  ante- 
flexion of  the  uterus ;  whilst,  if  the  patient  has  worn  pessa- 

318 


DIAGNOSIS.  319 

lies,  a  present  vaginitis  or  endometritis  may  be  explained, 
or  retroversion,  or  hernia  of  the  pelvic  floor  may  be  expected. 
So  also  the  patient  may  have  had  curetting,  trachelor- 
rhaphy, amputation  of  the  cervix,  perineorrhaphy,  or  ab- 
dominal section  performed,  and  these  will  all  shed  light  on 
the  present  condition. 

(c)  Menstruation. — The  age  of  the  onset  of  menstrua- 
tion, and  of  its  cessation  if  the  patient  be  past  the  meno- 
pause, should  be  noted ;  also  its  regularity,  duration,  the 
quantity  of  the  flow  as  estimated  by  the  number  of  diapers 
used,  and  its  association  with  pain.  It  is  important  to 
ascertain  whether  the  character  of  the  menses  has  altered  ; 
thus,  if  there  has  been  a  gradual  diminution,  followed  by 
cessation,  in  a  young  woman,  it  is  probably  due  to  anaemia ; 
diminution  in  an  adult  is  often  associated  with  ovarian 
tumors.  Increase  in  the  duration  and  quantity  will  point 
to  a  polypus,  to  retention  of  products  of  conception,  or  to 
pelvic  congestion  ;  it  may  be  due  to  a  fibro-myoma,  a  poly- 
pus, or  to  malignant  disease.  The  diagnosis,  especially  be- 
tween an  ovarian  tumor  and  a  fibro-myoma,  is  often  facili- 
tated by  a  careful  inquiry  as  to  menstrual  changes.  Recent 
amenorrhcea,  following  on  previous  regularity,  is  always 
suggestive  of  pregnancy.  When  the  menses  have  never 
appeared  and  the  patient  has  reached  adult  life  there  is  a 
likelihood  of  congenital  malformation,  with  or  without  re- 
tention of  menstrual  products. 

(d)  Confinements ;  Miscarriages. — The  patient  may 
give  a  history  of  sterility  after  several  or  many  years  of 
married  life.  This,  especially  if  associated  with  dysmenor- 
rhoea,  will  lead  one  to  suspect  under-development  of  the 
uterus,  or  if  there  is  at  the  same  time  a  history  of  gonor- 
rhoea, there  is  considerable  probability  of  disease  of  the 
uterine  appendages.  This  probability  is  increased  if  the 
sterility  has  supervened  after  a  single  pregnancy  or  after 
one  or  two  miscarriages ;  whilst  endometritis  will  at  the 
same   time   be   looked    out   for.     Relative    sterilit)-,    when 


320  DISEASES   OE   WOMEN. 

there  has  been  no  ^oiKurhdal  disease  and  when  the  men- 
strual loss  has  increased,  will  prepare  one  to  find  fibroid 
changes  ;  but  a  somewhat  similar  history,  with  recent  ir- 
re<j^ular  losses  followin^r  aii  apparent  miscarriage,  is  rather 
characteristic  of  tubal  gestation. 

Repeated  miscarriages  in  early  married  life,  followed  by 
delivery  of  a  viable  child,  usually  point  to  syphilis.  Re- 
peated miscarriages  coming  on  after  the  birth  of  several 
living  children  may  be  due  to  inflammation  or  displacement 
of  the  uterus. 

When  the  patient  is  a  multipara  who  has  had  several 
difficult  or  instrumental  labors,  one  is  likely  to  find  a 
laceration  of  the  cervix,  or  a  rupture  of  the  perineum  with 
its  attendant  symptoms  of  hernia  of  the  pelvic  floor. 

Recent  instrumental  or  otherwise  abnormal  labor  followed 
by  severe  illness  often  means  pelvic  inflammation,  either 
peritonitis  or  cellulitis ;  at  the  same  time,  this  may  follow  a 
labor  that  has  been  apparently  normal,  and  may  be  due  to 
the  reawakening  of  a  dormant  infection  in  the  vagina,  uterus, 
or  Fallopian  tubes  ;  to  a  suppurating  ovarian  cyst;  or  to  sec- 
ondary changes  in  a  dermoid. 

Metrorrhagia  or  menorrhagia  dating  from  a  miscarriage 
or  from  a  labor  at  term  is  most  often  due  to  the  retention 
of  portions  of  placenta  or  membranes. 

Various  vulvar  affections,  such  as  oedema,  haematoma, 
and  cellulitis,  may  owe  their  origin  to  a   recent  labor. 

(e)  The  history  of  the  present  illness  should  next 
be  inquired  into,  so  as  to  obtain  an  idea  as  to  its  mode  of 
origin  and  duration.  A  good  deal  of  care  is  necessary  in 
elucidating  this,  as  the  patient's  statements  arc  often  not 
only  vague,  but  contradictory.  Bleeding  that  has  lasted  a 
month  maybe  due  to  miscarriage;  irregular  bleeding  for 
two  or  three  months  may  indicate  tubal  gestation  or  can- 
cer ;  bleeding  that  has  gone  on  for  many  months  is  more 
likely  to  be  due  to  a  polypus  or  to  a  myoma.  So  also  a 
tumor  that  has  existed  many  months  without  much  increase 


DIAGNOSIS.  321 

in  size  cannot  be  due  to  pregnancy.  An  illness  that  has 
come  on  suddenly,  with  severe  pain,  generally  indicates 
I)elvic  inflammation,  but  it  may  also  be  due  to  tubal  ges- 
tation, to  the  rupture  of  a  cyst,  or  to  torsion  of  a  pedicle. 
The  history  of  new  growths  is  a  gradual  onset,  whilst  con- 
tlitions  such  as  chronic  endometritis  and  uterine  displace- 
ments have  probably  existed,  off  and  on,  for  several  years. 
The  history  of  tubal  disease  is  generally  that  of  chronic 
ill-health  with  periodic  exacerbations. 

(f )  Present  Symptoms. — In  the  out-patient  room  and 
in  the  consulting  room  the  symptoms  will  generally  be 
ascertained  at  the  outset ;  but  in  "  taking  out  a  case  "  in 
hospital  it  is  best  to  first  obtain  the  previous  history.  In 
many  gynaecological  conditions  the  symptoms  present  a 
marked  similarity;  thus,  pain  referred  to  the  sacrum  or 
hypogastrium,  and  pains  on  sitting  or  walking,  leucorrhcea, 
menorrhagia,  and  dysmenorrhoea,  may  be  met  with  in  the 
most  varied  diseases.  We  shall  attempt,  however,  to 
analyze  them  to  some  extent,  in  order  to  estimate  the  value 
to  be  attached  to  them  in  forming  a  diagnosis. 

Pain. — This,  when  referred  to  the  umbilicus  and  hypo- 
gastrium in  front  and  to  the  sacrum  behind,  generally  indi- 
cates uterine  disorder.  It  is  found  characteristically  as 
dysmenorrhoea.  It  is  said  that  the  pain  may  be  further 
localized,  and  that  sacral  pain  has  its  origin  in  cervical  con- 
ditions, whilst  when  the  fundus  is  involved  the  pain  is  re- 
ferred to  the  umbilicus.  This  view  receives  support  from 
the  fact  that  in  passing  a  sound  through  a  narrow  cervix  or 
internal  os  the  patient  often  complains  of  sudden  pain  in 
the  back,  whilst  on  touching  an  inflamed  fundus  abdominal 
pain  usually  results.  A  sense  of  aching,  fulness,  and  ill- 
defined  weight,  often  summed  up  by  the  patient  as  "  bear- 
ing-down pain,"  is  associated  with  pelvic  congestion,  and 
also  with  dragging  on  the  uterine  attachments,  as  in  cases 
of  prolapse  and  of  retroversion  of  a  heavy  fundus. 

Pain  in  the  iliac  regions  and  shooting  down  the  thighs  is 
21 


322  DISEASF.S   OF   WOMEN. 

often  due  to  conj^cstion  or  inflatiiination  of  tlic  uterine  ap- 
pcndat^cs,  but  it  is  also  a  frccjucnt  manifestation  of  neuras- 
tlienia,  when  it  may,  A///A'  dc  tniciix,  be  called  neuralj^ic. 

The  above  kinds  of  pain  may  occur  irregularly  or  almost 
continuously ;  they  may  come  on  as  the  result  of  long 
standing  or  much  walking;  and  they  are  then  worse  in 
the  evening.  Or  they  may  be  limited  to  the  menstrual 
periods. 

Lastly,  pain  ma)'  come  on  suddenly  and  acutel)'.  When  it 
is  situated  in  the  iliac  region,  the  most  frequent  causes  are 
rupture  of  an  ovarian  cyst,  pyosali)in.x,  tubal  gestation,  or 
torsion  of  the  pedicle  of  an  ovarian  tumor  or  cyst.  A  sud- 
den pain  referred  to  the  back  sometimes  marks  the  occur- 
rence of  displacement  or  of  inversion  of  the  uterus  as  the 
result  of  a  fall  or  strain. 

General  acute  abdominal  pain  is  usually  due  to  the  onset 
of  pelvic  inflammation. 

Lcucorrluva. — The  character  of  the  discharges  should  be 
carefully  inquired  into,  and  the  account  given  by  the  patient 
may  often  be  confirmed  by  the  subsequent  examination. 
The  information  to  be  derived  therefrom  has  already  been 
given  fn  discussing  the  secretions  (Chapter  XII.). 

Menorrhagia  and  ]\Ictrorr]iagia. — The  significance  of 
these  is  described  m  Chapter  XXXV. 

Rectal  and  Vesical  Symptoms. — Straining  at  stool, 
tenesmus  and  pain  preceding  and  during  the  action  of  the 
bowels,  arc  generally  due  to  pressure  on  the  rectum  due  to 
retroversion  of  the  uterus,  to  pelvic  inflammation,  or  to  a 
tumor  situated  more  especially  at  the  back  or  left  side  of 
the  pelvis.  Such  a  tumor  may  consist  of  a  subperitoneal 
myoma,  a  uniform  enlargement  of  the  uterus  from  fibro- 
myoma  or  pregnancy,  a  parovarian  cyst  in  the  recto-vaginal 
pouch,  or  a  cyst  in  the  left  broad  ligament.  Constipation  is 
favored  also  by  these  conditions,  and  the  pain  is  then  aggra- 
vated by  the  hardness  of  the  motions.  When  the  patient 
complains  of  "bearing  down  in  the  back  passage"  piles  are 


DIAGNOSIS.  323 

often  found,  due  in  part  to  constipation  and  pelvic  con- 
gestion. 

The  principal  bladder  symptoms  are  frequency  of  mic- 
turition, incontinence,  retention  of  urine,  and  burning  pain 
on  passing  water ;  both  frequency  and  incontinence  may  be 
of  nervous  origin  and  occur  in  anaemic  and  neurotic  girls. 
In  such  cases  the  absence  of  organic  cause  for  the  symp- 
toms is  shown  by  the  relief  which  follows  simple  hydro- 
static dilatation  of  the  bladder.  In  other  cases  these  condi- 
tions arise  from  moderate  pressure  on  the  neck  of  the 
bladder,  causing  continual  irritation.  If  the  pressure  be 
greater,  retention  results,  and  later  the  overflow  due  to 
retention — i.  c.  a  spurious  incontinence.  The  conditions 
which  give  rise  to  pressure  are  retroversion  of  a  gravid  or 
otherwise  enlarged  uterus,  pelvic  inflammation,  and  the 
jamming  of  the  uterus  against  the  pubes  by  a  growth  fill- 
ing the  recto-vaginal  fossa.  Burning  pain  on  passing  water 
is  always  found  with  gonorrhoea!  urethritis,  and  it  may 
occur  also  from  non-gonorrhoeal  leucorrhoeal  discharges, 
causing  peri-urethral  excoriation  and  irritation. 

General  Symptoms.— Under  this  heading  are  included 
symptoms  other  than  pelvic ;  thus,  a  patient  with  amenor- 
rhoea  may  complain  of  palpitation  and  shortness  of  *breath 
due  to  anaemia :  amenorrhoea  due  to  this  cause  does  not,  of 
course,  require  a  vaginal  examination.  Or  the  complaint 
may  be  of  one  or  more  of  the  reflex  functional  disorders 
above  enumerated :  this  will  necessitate  the  preliminary 
examination  of  the  organs  to  which  the  symptoms  are 
referred ;  if  these  organs  be  normal,  an  explanation  must 
be  sought  in  the  pelvis. 

Weakness,  headache,  anorexia,  etc.  occur  fn  almost  all 
cases  where  the  general  health  is  affected,  so  that  they  have 
but  little  diagnostic  value ;  but  loss  of  flesh  in  addition  may 
give  a  clue  to  the  presence  of  tuberculosis  or  malignant 
disease. 

The  evidence  to  be  obtained  by  questioning  the  patient 


324  DISEASKS   OF   WOMEN. 

has  been  set  forth  in  some  detail,  not  with  a  view  to  repla- 
cing physical  examination,  for  symptoms  are  proverbially 
unreliable,  but  rather  to  su^^^est  possibilities  and  direct  the 
course  of  further  examination.  Many  things  arc  missed 
simply  because  a  man  is  not  on  the  look-out  for  them,  whilst, 
on  the  other  hand,  it  is  in  a  measure  true  in  medicine  that 
"  the  eye  sees  that  which  it  brings  with  it  the  power  to  see." 
Consequently,  during  the  process  of  diagnosis  all  possibili- 
ties should  be  arrayed  and  retained  before  the  mind  until 
one  after  another  is  definitely  excluded  as  examination  pro- 
ceeds. By  this  means  little  will  be  missed,  though  at  the 
same  time  there  may  be  left  in  the  mind  at  the  conclusion 
of  examination  an  uncertainty  as  to  which  of  two  or  three 
conditions  is  actually  present. 


CHAPTER   XXXVII. 

DIAGNOSIS  (Continued). 

THE   PHYSICAL    EXAMINATION. 

(a)  General  HcaWi  and  Appearance. — The  information  to 
be  gained  under  this  head  comprises  (i)  evidences  of  fever, 
as  indicated  by  pulse  and  temperature,  by  extra  drj-ness  of 
the  skin,  or  by  sweating ;  (2)  evidences  of  wasting ;  (3)  in- 
dications of  the  general  nutrition  of  the  body.  In  the  face 
we  shall  read  signs  of  anaemia,  jaundice,  cachexia,  habitual 
suffering,  or  anasarca.  There  may  be  oedema  of  the  lower 
limbs,  or  varicose  veins,  indicating  backward  pressure  in 
thorax,  abdomen,  or  pelvis.  General  signs  of  under-devel- 
opment  may  be  noted,  such  as  a  childish  face,  smallness  of 
the  breasts,  a  narrow  pelvis,  and  deficiency  of  pubic  hair. 
Dark  mammary  areolae  and  the  presence  of  milky  secretion 
in  the  breasts  may  give  useful  information  as  to  a  previous 
or  present  pregnancy. 

(3)  Condition  of  the  Cardiac,  Respiratory,  Digestive,  Ex- 
cretory, a7id  Nervous  Systems. — This  part  of  the  examina- 
tion need  not  always  be  made  exhaustively,  but  no  well- 
marked  pathological  condition  should  ever  be  overlooked. 
Thus  when  there  has  been  sudden  pain  or  collapse  a  per- 
forated gastric  ulcer,  or  vermiform  appendix,  or  a  gall-blad- 
der with  impacted  stone  may  require  to  be  diagnosed  from 
tubal  gestation,  a.  ruptured  cyst,  or  pyosalpinx.  Renal  or 
biliary  colic  may  simulate  pelvic  pain. 

ic)  The  Abdomen. — Note  the  presence  of  stric-e  as  in- 
dicating former  distention,  and  dilatation  of  superficial  veins 
as  evidence  of  intra-abdominal  pressure. 

325 


326 


DISEASES   OF   WOMEN. 


Swelling  of  the  abdomen  may  be  due  to  the  following 
conditions : 

(i)  Causing  uniform  or  regular  enlargement:  Deposition 
of  fat,  especially  at  the  menoi)ause ;  distention  due  to  flatus; 
ascites  and  tubercular  peritonitis ;  pregnancy ;  uniform 
enlargement  of  the  uterus  from  fibro-myoma  ;  large  ovarian 
tumors ;  large  hydronephrosis. 

(2)  Causing  irregular  enlargement :  Small  ovarian  tumors  ; 
encysted  peritoneal  effusions  ;  myomata  ;  moderate  enlarge- 


Hepatic 
enlargement. 


Pelvic  cellulitis. 
0:'arian  tumor. 
Tubal  pregnancy. 


Fig.  94. — Diagram  to  indicati;  ihc  po.siiioiib  of  abdumiiial  swellings  (A.  E.  G  ). 

ment  of  kidney  from  hydronephrosis  or  new  growth — mov- 
able kidney  ;  enlarged  spleen  ;  omental  tumors  ;  malignant 
disease  of  the  intestines  ;  ectopic  gestation  (Figs.  94,  95). 

We  must  begin  by  excluding  the  first  two  conditions  : 
palpation  and  percussion  will  generally  suffice,  especially 
under  an  anaesthetic.  Ascites  is  indicated  b\-  the  absence  of 
definite  limits,  the  dulness  in  the  flanks  and  hypochondrium 


DIAGNOSIS. 


3^7 


with  resonance  in  the  epigastrium,  the  h'nc  of  duhicss  hav- 
ing a  margin  concave  toward  the  umbilicus,  and  tiie  varia- 
tions in  duhiess  on  altering  the  position  of  the  patient.  An 
encysted  collection  of  peritoneal  fluid  may,  however,  have 
fairly  definite  margins,  unaltered  by  the  position  of  the 
patient,  and  lie  excentrically. 

The  next  question  is,  Does  the  swelling  originate  in  the 
pelvis  ?     If  so,  palpation  cannot  reach  its  lower  margin  ;   if 


splenic  enlargement. 
Renal  swelling. 

Ovarian  cyst, 
pregnancy,  6th  mth., 
or  myoma. 
Pregnancy, ^th  mth., 
or  myoma. 

Pregnancy ,  4th  mth., 
myoma  or  distended 
bladder. 


Fig.  95. — Diagram  to  indicate  the  positions  of  abdominal  swellings  (A.  E.  G.). 


we  find  the  swelling  median  and  uniform,  it  is  probably  a 
gravid  uterus,  a  uterine  myoma,  or  a  large  ovarian  tumor ; 
if  arising  laterally,  it  may  be  a  small  ovarian  tumor,  a  fibro- 
myoma,  an  ectopic  gestation,  or  pelvic  inflammation. 

If,  on  the  other  hand,  the  lower  limit  can  be  defined,  we 
have  to  do  with  an  abdominal  tumor.  If  left-sided,  smooth, 
passing  up  under  the  left  costal  margin,  and  superficially 
dull,  it  is  probably  spleen.     If  nearer  the  middle  line,  and 


328  DISEASES   OF   WOMEN. 

disappearing  under  the  costal  margin,  with  an  area  of  reso- 
nance superficial  to  it,  it  is  probably  renal.  A  movable 
kidney  will  be  definable  above  and  below.  An  isolated 
and  well-defined  tumor  somewhere  near  the  umbilicus  is 
probably  an  omental  tumor,  malignant  disease  of  the  intes- 
tines, or  a  pancreatic  cyst. 

(d)  Vaginal  Examination. — It  is  frequently  advisable  to 
begin  with  an  inspection  of  the  genital  organs ;  for,  in  the 
first  place,  we  may  thus  avoid  the  risk  of  infection  from 
gonorrhoeal  discharges  and  from  syphilitic  sores  ;  and,  sec- 
ondly, we  shall  note  the  existence  of  malformations  of  the 
vulva,  cutaneous  affections,  and  enlargement  of  the  nympha^, 
indicating  irritation,  kraurosis  vulvae,  and  laceration  of  the 
perineum :  these  present  no  difficulty  in  diagnosis.  We 
shall  also  determine  the  presence  of  swelling  in  the  vulva, 
such  as  haematoma,  labial  cysts,  labial  abscess,  etc. 

On  introducing  the  finger  we  note  the  condition  of  the 
hymen,  and  the  pain  and  spasm  so  induced  may  indicate 
vaginismus.  At  this  stage  the  character  of  the  secretion 
should  be  observed  :  if  muco-purulent,  we  shall  find  inflam- 
mation higher  up ;  if  malodorous,  we  may  ha\e  to  do  with 
carcinoma,  a  sloughing  myoma,  a  polypus,  or  a  retained 
pessary. 

If  we  find  the  vaginal  walls  protruding,  the  case  is  prob- 
ably one  of  cystocele  or  rectocele ;  and  this  may  be  con- 
firmed, if  necessary,  by  passing  a  sound  into  the  urethra  or 
the  finger  into  the  rectum. 

Heat  and  dryness  of  the  vagina  indicate  pelvic  inflamma- 
tion ;  heat  and  great  moisture  indicate  vaginitis  or  pcKic 
congestion  ;  the  latter  may  be  due  to  pregnancy,  in  which 
case  we  shall  find  the  well-known  purple  coloration. 

Marked  pulsation  of  the  vaginal  vessels  is  most  often 
due  to  pregnancy  or  uterine  myoma ;  if  confined  to  one 
fornix,  there  is  probably  tubal  disease  or  tubal  gestation. 

At  this  stage  w^e  shall  discover  swellings  in  the  vagina 
due  to  cysts  or  to  lateral  ha^matometra :  the  exact  diag- 


DIAGNOSIS.  329 

nosis  will  probably  require  aspiration  with  a  fine  trocar. 
Growths  affecting  the  vagina  will  be  recognized  without 
difficulty,  but  we  may  find  other  things  projecting,  such  as 
polypus  or  an  inverted  uterus,  which  must  be  investigated 
as  previously  described.  The  condition  of  the  cervix  next 
occupies  us — lacerations,  erosion,  faulty  position,  softness 
due  to  pregnancy,  malformations,  cancer,  the  patulousness 
or  otherwise  of  the  os  externum.  If  the  cervix  be  normal 
in  these  respects,  we  proceed  at  once  to  ascertain  the  posi- 
tion, mobility,  and  size  of  the  uterus  by  bimanual  examina- 
tion. If  the  position  be  faulty,  it  may  be  due  to  a  simple 
displacement,  to  pelvic  inflammation,  or  to  the  distortion 
due  to  a  tumor  pressing  on  it ;  fixedness  may  also  be  due 
to  one  of  the  last  two  conditions.  If  pelvic  inflammation 
be  present,  it  will  be  indicated  by  the  board-Hke  hardness, 
converting  the  structures  at  the  summit  of  the  vagina  into 
a  kind  of  firm  roof.  The  position  and  limits  of  the  effusion 
are  determined  by  bimanual  examination,  and  the  parts  will 
usually  be  very  tender  to  manipulation.  A  large,  soft, 
movable  uterus  is  nearly  always  indicative  of  pregnancy ; 
this  may  be  simulated  by  a  soft  fibro-myoma,  and  in  diag- 
nosing the  condition  we  shall  have  to  be  guided  by  the 
history,  especially  the  suppression  or  increase  of  menstrua- 
tion, and  by  the  age  of  the  patient,  for  fibro-cystic  tumors 
generally  occur  after  forty,  whilst  pregnancy  is  then  less 
common.  The  possibility  of  hsematometra  in  one-half  of  a 
double  uterus  or  in  the  single  organ  must  be  borne  in 
mind.  If  pregnancy  can  be  excluded,  the  sound  may  be 
passed,  and  this  will  show  whether  and  how  much  the 
uterus  is  enlarged.  If  it  passes  not  more  than  three  and  a 
half  inches,  the  enlargement  may  be  due  to  subinvolution, 
chronic  metritis,  hypertrophy  of  the  cervix,  a  small  polypus 
or  retained  products  of  conception  :  to  further  determine 
which  of  these  conditions  is  present,  the  cervix  must  be 
dilated  and  the  uterine  cavity  explored  with  the  finger.  If 
the  sound  passes  from  three  and  a  half  to  six  inches,  we 


330  DISEASES   OF   U'OAfEN. 

lia\'c  to  do  with  a  fibroniyonia  of  the  uterus,  as  a  rule. 
lUit  sarcoma  and  carciiionia  of  the  body  of  tlie  uterus  may 
also  cause  considerable  enlargement ;  the  free  bleeding  on 
passing  the  sound  will  give  a  clue;  and,  in  addition,  the 
uterus  may  be  more  or  less  fixed.  It  must  be  remembered 
also  that  in  lateral  ha^niatometra  the  patent  half  of  the 
uterus  may  be  considerably  elongated. 

Supposing  the  uterus  to  be  fairly  normal,  we  next  ex- 
amine the  adnexa.  An  endeavor  should  first  be  made  to 
trace  the  Fallopian  tubes  from  the  cornua  of  the  uterus 
outward :  if  normal,  they  will  be  felt  bimanually  as  cord- 
like structures,  and  in  some  part  of  their  course  we  shall 
meet  the  ovaries,  whose  position  will  be  generally  indicated 
by  their  tenderness  to  pressure  and  the  shrinking  of  the 
patient.  If  enlarged,  the  tubes  will  be  felt  as  elongated 
swellings :  the  thickening  may  extend  right  up  to  the 
uterus  or  it  may  affect  principally  the  distal  portions.  At 
the  same  time  a  small  ovarian  cy.st  or  a  distended  tube  may 
be  discovered.  Enlargement  of  the  ovaries,  tubes,  and 
broad  ligaments  can  often  be  more  distinctly  felt,  and  their 
limits  better  ascertained,  by  recto-abdominal  examination. 
Sometimes  tubal  and  ovarian  swellings  are  found  occupy- 
ing the  pouch  of  Douglas,  which  they  may  depress  so  as 
to  obliterate  the  posterior  vaginal  fornix.  A  mass  is  then 
felt  behind  the  vagina,  and  rectal  examination  may  be 
necessary'  to  determine  whether  the  mass  is  between  the 
vagina  and  rectum  or  in  the  rectum  itself,  for  scybala  in 
the  rectum  give  much  the  same  sensation.  And  here  we 
may  remark  that  the  feeling  of  a  swelling  in  the  pouch  of 
Douglas  or  in  the  left  broad  ligament  may  be  so  closely 
simulated  by  malignant  disease  affecting  the  sigmoid  flex- 
ure that  a  rectal  examination  is  necessary  to  clear  up  the 
diagnosis.*  It  is  often  impossible  to  distinguish  between 
tubal  disease  and  small  ovarian  or  broad-ligament  cysts. 
When  double  and  following  on  an  attack  of  gonorrhoea 
the  probability  is  in  favor  of  tubal  disease;    but  bilateral 


DIAGNOSIS. 


331 


ovarian  cysts  are  not  uncommon.  It  is  then  sometimes 
possible  to  feel  the  tube  passing  over  the  swelling,  or,  when 
the  tubes  are  affected,  the  ovaries  may  be  felt  separately. 
On  the  right  side  tubal  disease  is  often  closely  simulated  by 
disease  of  the  vermiform  appendix.  The  history  will  serve 
as  a  guide ;  but  sometimes  the  diagnosis  can  only  be  made 
after  the  abdomen  is  opened. 

The  consistency  of  a  small  pelvic  tumor  is  often  very  mis- 
leading, so  that  a  tense  cyst  may  be  mistaken  for  an  out- 
lying myoma,  and  vice  versa.  When  a  mass  of  some  size 
occupies  the  recto-vaginal  pouch  we  may  have  to  distinguish 
between  a  cyst,  an  enlarged  retroverted  uterus,  a  subperi- 
toneal myoma,  and  a  haematocele.  If  the  passage  of  the 
sound  be  contraindicated,  this  is  sometimes  difficult;  but 
careful  examination  under  an  anaesthetic  may  enable  us  to 
feel  the  fundus  of  the  uterus  distinct  from  the  tumor.  A 
haematocele  under  such  circumstances  will  generally  be  due 
to  rupture  and  subsequent  encystment  of  a  tubal  gestation  ; 
but  it  may  also  be  due  to  tubal  abortion. 

Tubal  disease,  extra-uterine  gestation,  and  small  cysts, 
especially  when  suppurating,  may  be  complicated  by  pelvic 
inflammation  :  it  will  then  be  necessary  to  wait  until  this  is 
partly  absorbed  before  the  nature  of  the  original  swelling 
can  be  made  out. 

In  the  case  of  large  pelvic  tumors  the  diagnosis  lies 
principally  between  fibro-myomata  of  the  uterus  and  ovarian 
cysts.  The  latter  may  be  partly  solid  or  the  former  fibro- 
cystic, w^hen  the  difficulty  will  be  increased.  The  menstrual 
history  is  here  of  great  service,  for  increase  of  menstruation 
is  the  rule  in  fibro-myomata,  cystic  or  otherwise,  while  it  is 
the  exception  in  the  case  of  ovarian  tumors.  For  further 
diagnosis  we  may  pass  the  sound  :  if  the  uterine  cavity  be 
of  normal  length,  the  tumor  is  extra-uterine.  And  the 
same  may  usually  be  said  when  the  tumor  can  be  moved 
independently  of  the  uterus,  though  at  times  a  large  sub- 
peritoneal myoma  may  have  a  long,  thin  pedicle.     If  the 


332  DISEASES   OF   IVOMEA'. 

fundus  can  be  felt  bimanually  independent  of  the  tumor,  as 
can  often  be  made  out  under  an  anaesthetic,  the  tumor  is 
probably  ovarian :  it  will  generally  be  found  in  such  a  case 
that  the  fundus  has  been  jammed  up  a<;ainst  the  pubes  or 
backward  into  the  cavity  of  the  sacrum  by  the  ^rowin^ 
tumor.  It  must  be  remembered  that  an  ovarian  tumor  and  a 
uterine  myoma  sometimes  coexist;  that  cither  may  be  found 
complicating  pregnancy ;  and  that  in  rare  cases  any  one  of 
the  three  may  be  found  in  connection  with  a  double  uterus. 
In  all  these  cases  the  diagnosis  is  very  difficult,  and  no 
general  rules  can  be  laid  down.  Cceliotomy  will  probably 
be  required  before  an  exact  diagnosis  can  be  made. 

We  have  not  attempted  to  do  more  than  give  an  outline 
of  the  principles  of  diagnosis  in  examining  the  female 
genital  organs  ;  and  in  conclusion  we  should  like  to  empha- 
size three  points : 

Firstly,  the  necessity  of  exploration  of  the  cavity  of  the 
uterus  when  symptoms  point  to  intra-uterine  mischief  and 
the  cervix  is  comparatively  normal. 

Secondly,  the  great  advantage  to  be  gained  by  combining 
a  rectal  examination  with  the  bimanual  method. 

Thirdly,  the  importance  of  an  examination  under  an 
anaesthetic  in  all  cases  of  doubt.  By  this  means  the 
abdominal  muscles  are  relaxed ;  the  resistance  of  the  pa- 
tient due  to  pain  and  tenderness  is  obviated,  and,  perhaps 
most  important  of  all,  the  examination  can  be  made  in  the 
lithotomy  position,  which  is  the  only  position  in  which  all 
parts  of  the  pelvis  can  be  thoroughly  explored  in  their 
natural  relations. 


CHAPTER    XXXVIII. 

GYNyECOLOGICAL   OPERATIONS. 

Operative  procedures  upon  the  female  genital  organs 
permit  of  division  into  two  groups — I.  Vaginal  operations; 
2.  Abdominal  operations. 

Both  groups  demand  for  their  successful  performance  the 
same  qualities  of  head  and  hand  as  are  necessary  for  carry- 
ing out  operations  in  other  regions  of  the  body.  The  indi- 
vidual ambitious  for  success  in  operative  gynaecology  must 
possess  a  sound  practical  knowledge  of  pelvic  anatomy 
and  pathology,  and  carry  out  rigidly  all  the  details  of  what 
is  known  as  aseptic  surgery.  The  more  thoroughly  he 
attends  to  the  preliminary  preparation  of  the  patient,  the 
selection  of  the  room  and  surroundings,  and  the  more  care 
he  devotes  to  the  sterilization  of  the  instruments  and  mate- 
rials employed  in  operations,  the  greater  will  be  his  measure 
of  success. 

To  facilitate  the  sterilization  of  instruments  it  is  now  usual 
to  have  them  made  of  metal  throughout.  Of  course  all  cut- 
ting instruments  are  made  of  steel,  but  knives  may  be  fitted 
to  handles  which  are  coated  with  nickel,  so  that  they  retain 
their  brightness. 

It  is  assumed  that  the  student  before  he  begins  the  study 
of  gynaecology  has  been  a  dresser,  and  is  already  familiar 
with  the  common  tools  of  surgery,  such  as  knives,  dissect- 
ing-forceps,  artery-forceps,  pressure-forceps,  needle-holders, 
retractors,  and  the  like.  He  should  also  be  familiar  with 
the  various  kinds  of  material  employed  to  secure  blood- 
vessels and  wounds,  such  as  catgut,  fishing  or  silkworm  gut, 
and  silk.     His  occupation  of  dresser  will  have  made  him 

333 


334  DISEASES   OF   WOMEN. 

acquainted  with  the  various  kinds  of  material  used  as  dress- 
ings for  wounds. 

Although  a  large  number  of  gyna.'Cological  operations 
may  be  carried  out  with  the  assistance  of  the  implements 
employed  in  general  surgery,  nevertheless  there  are  certain 
instruments  indispensable  to  the  performance  of  vaginal 
operations.  Some  of  these,  such  as  the  speculum,  the 
uterine  sound,  and  the  volsella,  have  already  been  described 
in  Chapter  III.  Others  will  be  considered  with  the  opera- 
tions in  which  they  are  of  special  service. 

The  student  should  realize  that  it  is  part  of  his  duty  to 
make  himself  familiar  with  the  names  of  the  instruments  as 
well  as  to  understand  their  use.  If  he  has  the  least  taste 
for  mechanics,  there  is  much  to  interest  him  in  the  construc- 
tion of  surgical  instruments,  and  there  is  need  also  for  im- 
provement :  the  names  of  some  great  surgeons,  famous  in 
their  day  for  operative  ability,  are  saved  from  utter  oblivion 
by  the  fact  of  being  associated  with  the  invention  or  im- 
provement of  some  useful  instrument  of  surgery.  Thus 
the  history  of  instruments  employed  in  special  departments 
of  surger}'  is  indirectly  the  history  of  the  specialty. 

In  gynaecology,  as  in  other  departments  of  surgery,  many 
operations  are  carried  out  upon  definite  principles,  the  out- 
come of  the  accumulated  experience  of  many  operators. 
The  student,  however,  should  remember  that  the  descrip- 
tion of  an  operation  is,  in  fact,  merely  a  narration  of  prin- 
ciples :  the  details  require  modification  according  to  the 
necessities  of  the  case  and  the  complications  which  may 
arise  during  its  performance. 

Before  embarking  upon  an  operation  the  surgeon  should 
satisfy  himself  that  the  patient  has  no  constitutional  defect 
likely  to  militate  against  success.  Thus  chronic  renal  dis- 
ease, diabetes,  leucocyth.emia,  haemophilia,  malaria,  chronic 
alcoholism,  and  visceral  disease  are  conditions  which  need 
to  be  carefull}'  considered  in  advising  patients  to  submit  to 
operations  which   are   not   urgently   necessar}'.      In   grave 


GYNECOLOGICAL    OPKRATIONS.  335 

conditions  wlicrc  life  is  in  imminent  peril,  where  nothinL^ 
short  of  operation  (so  far  as  human  foresight  enables  one 
to  judge)  holds  out  any  prospect  of  prolonging  life,  then 
the  constitutional  defect  is  not  allowed  to  bar  operative 
interference. 

In  arranging  for  operation  in  women  during  the  sexual 
period  of  life  there  is  one  function  almost  invariably  to  be 
considered — namely,  menstruation. 

Operative  procedures  on  the  external  genital  passages 
are  barred  during  menstruation,  and,  as  a  rule,  the  patients 
themselves  fix  the  day  of  operation  according  to  their 
knowledge  of  the  expected  appearance  or  disappearance 
of  the  menstrual  flow.  It  must,  however,  be  borne  in  mind 
that  with  many  women  the  anxiety  occasioned  by  an  ex- 
pected operation  will  defer  or  even  arrest  a  menstrual 
period,  but  more  frequently  it  anticipates  the  regular 
date. 

When  a  woman  is  suffering  from  intra-uterine  myoma, 
carcinoma,  or  retained  products  of  conception,  uterine  bleed- 
ing is  no  obstacle  to  operation,  but  necessitates  it. 

In  abdominal  operations,  such  as  ovariotomy  or  oopho- 
rectomy, it  is  the  rule  not  to  operate  during  menstruation, 
but  occasionally  the  environment  of  a  patient  is  such  that 
the  surgeon  neglects  to  regard  it.  Operations  of  this  kind 
performed  during  menstruation  do  very  well,  and  we  have 
never  seen  anything  untoward  arise  in  such  circumstances. 

The  ensuing  accounts  of  operations  will  not  be  merely 
descriptions  of  the  methods  of  performing  them,  but  will 
contain  information  concerning  the  various  sequela;  and 
remote  effects,  as  well  as  the  immediate  risks  to  life. 

In  order  to  prevent  repetition  it  will  be  useful  to  describe 
the  preliminary  preparation  of  the  patient. 

In  all  operations  belonging  to  this  group  it  is  important 
to  secure  the  services  of  a  nurse  w^ho  has  had  a  gynaeco- 
logical training.  Such  a  nurse  understands  the  methods 
of  washing  and  disinfecting  the  vagina,  is  apt  at  passing  the 


336  DISEASES   OF   WOMEN. 

catheter,  and  without  fuss  arranges  the  patient  and  prepares 
the  needful  apparatus.  For  any  operation  under  an  anaes- 
thetic the  patient  sliould  abstain  from  food  fcjr  at  least  four 
hours — six  is  preferable :  this  not  only  prevents  vomiting 
during  the  exhibition  of  the  drug,  but  diminishes  the  chances 
of  its  occurrence  on  the  return  to  bed.  As  in  other  cases, 
the  rectum  should  be  thoroughly  emptied  by  an  enema 
some  hours  before  the  time  fixed  for  the  operation. 

It  is  good  practice  to  have  the  nurse  in  attendance  upon 
the  patient  at  least  forty-eight  hours  before  operation  :  they 
grow  accustomed  to  each  other,  and  the  nurse  is  able  to 
douche  the  vagina  systematically — an  important  matter 
when  there  is  a  purulent  or  offensive  discharge.  In  ordi- 
nary cases  a  douche,  morning  arfd  evening,  of  a  quart  of 
warm  water  lightly  tinged  with  permanganate  of  potash 
answers  every  purpose.  When  the  discharges  are  offensive, 
then  it  will  be  necessary  to  employ  a  lotion  of  perchloride 
of  mercury  (i  :  5000). 

The  room  (when  there  is  opportunity  for  choice)  should 
be  well  lighted  and  well  ventilated.  If  near  a  bath-room 
or  water-closet,  the  surgeon  should  satisfy  himself  that 
these  offices  arc  in  a  sanitary  condition. 

In  all  vaginal  operations  the  patient  lies  upon  her  back, 
fixed  in  what  is  known  as  the  lithotomy  position  by  means 
of  the  crutch  (Fig.  96).  Her  buttocks  are  brought  well  to 
the  edge  of  the  table,  and  a  piece  of  waterproof  sheeting 
adjusted  so  as  to  convey  any  fluid  or  discharges  into  a  con- 
v^enicnt  receptacle.  The  table  should  be  so  arranged  as  to 
face  a  window  free  from  the  encumbrance  of  thick  blinds  or 
curtains. 

The  Crutch. — This  invaluable  instrument  consists  of 
two  stout  circular  bands  fitted  with  leather  straps  and 
buckles  for  grasping  the  legs  just  below  the  knees:  the 
bands  are  fitted  to  a  sliding  cross-bar  of  iron  which  can  be 
lengthened  at  will  by  means  of  a  thumb-screw.  When 
fixed  to  the  legs  the  patient  can  be  secured  in  the  lithotomy 


G  YNMCOL  O GICAL    OPERA  TIONS. 


337 


position   by  a   broad   strap   passing    obliquely   aroimd   the 
shoulders  (Fig.  97). 


Fig.  96. — Crutch  for  securing  a  patient  in  the  lithotomy  position. 

Every  well-trained  nurse  in  arranging  for  a  vaginal  ope- 
ration prepares  the  following  things  : 
I.  A  firm  and  convenient  table; 
22 


33^  DISEASES   OE   WOMEN. 

2.  Waterproof  sheeting; 

3.  A  dozen  towels  ; 

4.  Plenty  of  warm  watpr; 

5.  Douche-can  ; 

6.  Cotton-wool ; 

7.  Catheter; 

8.  Some  good  brandy  ; 

9.  Vessels  in  which  to  immerse  the  instruments ; 


Fig.  97.— Patient  secured  in  the  lithotomy  position  by  means  of  a  crutch. 

10.  Antiseptic  lotions  according  to  in.structions  ; 

1 1.  Vaselin  or  glycerin  ; 

12.  Tampons. 

In  the  performance  of  vaginal  operations  certain  instru- 
ments are  indispensable,  and  it  will  save  much  repetition  to 
enumerate  them  : 

1.  The  crutch   for  fixing  the  patient  in   the   lithotomy 

position  ; 

2.  The  duck-bill   speculum  for  exposing  the  area  of 

operation  ; 


G  YN/ECOL  O GICA L    OPERA  TIONS. 


339 


3.  The  uterine  sound  for  determining  the  lenc^th  of  the 

uterine  cavity  and  the  position  of  the  uterus  ; 

4.  The  vesical  sound  to  indicate   the  position  of  the 

bladder ; 

5.  Volselhe  for  manipulating  the  uterine  cervix; 

6.  Sponge-holders ; 

7.  Sterilizer. 

The  Steriliser. — A  convenient  and  portable  form  for 
sterilizing  instruments  is  shown  in  Fig.  98.     It  is  made  of 


Fig.  98. — Convenient  form  of  sterilizer. 


copper  and  stands  on  four  legs,  which  leave  sufficient  space 
for  a  spirit-lamp  or  gas-jet  to  be  placed  underneath.  The 
sterilizer  is  half  filled  with  hot  water,  the  instruments  placed 
in  the  wire  basket,  immersed  in  the  water ;  the  lid  is  closed 
and  the  boiling  maintained  for  twenty  minutes.  A  new 
fish-kettle  makes  an  excellent  sterilizer. 

In  describing  the  various  vaginal  operations  and  in  enu- 
merating the  requisite  instruments  it  will  be  assumed  that 


340 


DISEASES   OF   WOMEN. 


the  operator  is  alrcati)-  furnishcxl  with  those  nicMtionLtl  in 
the  above  hst. 

The  operations  will  be  described  in  this  order: 

riK(nM'   I. — Vaginal  Operations. 
A.  The  Perineum.         Perineorrhaphy. 


B.  The  Vulva. 

C.  The  Vagina. 

D.  The  Uterus. 


Removal  of  urethral  caruncle  ; 
Removal  of  the  clitoris  ; 
Tumors  and  cysts  of  the  labia. 
Colporrhaphy ; 
Vaginal  fistuht ; 

For  atresia  of  the  genital  passage. 
Dilatation  and  curetting ; 
Vaginal  myomectomy ; 
Trachelorrhaphy ; 
Amputation  of  the  cervix  ; 
Vaginal  hysterectomy  ; 
Colpotomy. 


CHAPTER   XXXIX. 

OPERATIONS    ON   THE    PERINEUM,    VULVA,  AND 
VAGINA. 

PERINEORRHAPHY;  REMOVAL  OF  URETH- 
RAL CARUNCLE;  REMOVAL  OF  CLITORIS; 
COLPORRHAPHY. 

Perineorrliaphy. — Under  this  term  are  included  the 
various  operations  performed  for  the  repair  of  lacerations 
of  the  perineal  body  in  the  female. 

Many  methods  of  operating  have  been  devised  for  this 
purpose,  but  they  have  been  greatly  modified  in  the  last 
fifteen  years,  with  the  result  that  it  has  become  one  of  the 
simplest,  safest,  and  most  certain  of  all  gynaecological  ope- 
rations, providing  care  is  exercised  in  the  preparation  of 
the  patient,  in  the  details  of  the  operation,  and  in  the  after 
treatment. 

Perineorrhaphy  may  be  described  in  two  sections  : 

1.  When  the  lacerationis  partial; 

2.  When  the  laceration  is  complete. 

Preparation  of  tJic  Patient. — To  ensure  success  it  is  ne- 
cessary that  the  patient  be  confined  to  bed  for  a  few  days, 
and  her  bowels  should  be  thoroughly  and  regularly  evacu- 
ated. The  vagina  is  douched  twice  daily  with  a  solution 
of  permanganate  of  potash,  and  if  there  be  a  purulent 
discharge  from  vaccina  or  cervical  canal,  this  should  be 
treated  thoroughly  before  any  attempt  is  made  to  repair 
the  perineum. 

Instruments  required  in  addition  to  those  enumerated  on 

P-  338  • 

Scissors,  angular  and  flat ;  haemostatic  forceps  ;  silkworm 

341 


342 


DISEASES   Oh    WOMEN. 


^iit ;    silver   wire;    perforated   shot   and   coils;   needles    in 
hancilcs  ;  shot-compressor. 

Partial  I/aceration  of  the  Perineum. — The  jxitient 
is  fixed  in  the  lithotomy  position,  and  the  operator  intro- 
duces the  first  two  fingers  of  the  left  hand  into  the  anus, 


Fig.  99. — Perineorrhaphy  :  first  stage,  the  raising  of  the  flap  (Kancourt  Barnes). 

SO  as  to  put  the  parts  in  front  on  the  stretch.  With  a  pair 
of  sharp-pointed  angular  scissors  the  vaginal  mucous  mem- 
brane is  raised  up  as  a  flap  by  splitting  the  recto-vaginal 
septum,  and  the  flap  is  carried  up  on  each  side  as  far  as  the 
original  limit  of  the  perineal  body  (Fig.  99). 

No  attempt  is  made  to  arrest  the  bleeding,  but  the  assist- 


OPERATIONS   ON  PERINEUM,    I'i'LJ'A,   AND    VAGINA.    343 

ant  keeps  the  field  of  operation  clear  by  repeated  applica- 
tion of  a  sponge  or  moistened  cotton-wool  dabs.  Care 
should  be  taken  not  to  buttonhole  the  vaginal  flap  while  it 
is  being  raised. 

As  soon  as  the  flap  is  sufficiently  raised,  it  is  held  up  by 
the  assistant  with  a  pair  of  forceps  whilst  the  sutures  are 


1      0 

Fig.  100. — Perineorrhaphy  :  second  stage,  the  sutures  in  position  (Fancourt  Barnes). 

inserted.     These  may  be  of   silkworm  gut  or  silver  wire 
according  to  fancy.     They  are  introduced  thus  :  A  needle 


344 


DISEASES   OJ-    WOMEN. 


ill  liaiullc  curved  at  right  angles  (or  it  may  possess  a  simple 
terminal  curve)  is  introduced  at  the  skin  margin  on  one  side 
and  buried  deeply  in  the  tissues,  and  then  brought  across 
the  gap  and  through  the  opposite  half  of  the  perineum,  so 


^"-  '"^s^^Mk,^. 


Fig.  ioi. — Perineorrhaphy  :  third  stage, showinR  method  of  fastening  the  sutures 
(after  Fancourt  Barnes). 

that  its  point  emerges  at  the  skin  margin  corresponding  in 
position  to  its  point  of  entrance  on  the  opposite  side  (Fig- 
lOo).     During  this  procedure  the  fingers  of  the  left  hand 


OPERATIONS   ON  PERINEUM,    VULVA,   AND    VAGINA.    345 

arc  kept  in  the  rectum  to  ensure  that  the  needle  in  its  pas- 
sage does  not  perforate  it. 

The  first  suture  is  introduced  near  the  anal  end  of  the 
perineum,  and  the  remainder  are  continued  in  series  till  suf- 
ficient have  been  passed  to  bring  the  parts  well  together. 
In  an  ordinary  case  three  or  four  are  sufficient.  The  ope- 
rator pleases  himself  whether  he  arms  the  needle  with  the 
suture  before  passing  it,  or  threads  it  after  transfixing  the 
tissues. 

The  mode  of  securing  the  sutures  is  of  some  import- 
ance. It  is  usual  to  run  a  small  coil  of  silver  wire  along 
the  two  projecting  ends  of  the  silkworm  gut  or  wire,  and 
then  draw  the  ends  through  a  perforated  shot :  the  parts 
are  then  drawn  sufficiently  tight  and  the  shot  secured  by 
squeezing  it  with  the  shot-compressor  (Fig.  loi). 

It  is  usually  necessary  to  introduce  here  and  there  a 
superficial  suture  to  keep  the  flap  of  mucous  membrane 
well  up  to  the  skin-margin. 

The  great  advantage  of  fastening  the  sutures  with  shot 
and  coil  is  that  it  greatly  facilitates  their  removal,  for  it  is 
only  necessary  to  cut  through  the  upper  part  of  the  coil, 
thus  removing  the  shot.  The  coil  then  slips  off  and  leaves 
the  end  of  the  suture  exposed,  thus  enabling  it  to  be  with- 
drawn. 

Complete  I/aceration  of  the  Perineum. — When  the 
split  involves  the  margin  of  the  anus,  without  passing 
through  the  sphincter,  its  repair  is  carried  out  on  the  lines 
above  described.  When  the  sphincter  is  involved  the  tear 
usually  extends  some  distance  up  the  anterior  wall  of  the 
rectum  and  the  operation  has  three  objects  :  (i)  to  provide 
a  posterior  wall  for  the  vagina ;  (2)  to  form  an  anterior  wall 
for  the  rectum ;  (3)  to  form  a  new  perineum  between  these 
two  structures.  The  first  object  is  secured  by  raising  a  flap 
toward  the  vagina  by  splitting  the  recto-vaginal  septum,  as 
above  described.  The  second  object  is  attained  as  follows  : 
A  flap  is  taken   up  on  each  side  of  the  anterior  part  of  the 


34(3  DISEASES   OF   WOMEN. 

rectum,  h)'  carrj-iiii^  the  dissection  backward  in  a  fashion 
correspc)iuiinL(  to  that  by  which  the  anterior  flap  is  raised 
by  carrying  the  dissection  forward.  The  total  superficial 
incision  is  thus  H-shaped,  the  upper  limbs  of  the  H  passing 
forward  b)'  the  sides  of  the  vaginal  orifice,  the  posterior 
limbs  backward,  just  external  to  the  margin  of  the  anus, 
and  the  cross-bar  consisting  of  the  transverse  split  in  the 
recto-vaginal  septum.  The  posterior  or  side  flaps  are 
turned  backward  and  in\\ard,  and  secured  together  by  a 
continuous  catgut  suture.  There  is  now  a  raw  surface, 
shaped  like  a  p)'raniid  with  its  base  superficial :  the  ante- 
rior borcler  of  this  base  is  formed  by  the  anterior  flap ;  the 
posterior  border  by  the  joined  posterior  flaps;  the  sides  of 
the  base  are  formed  by  the  skin-edges,  and  when  brought 
together  carry  out  the  third  object  above  mentioned,  the 
formation  of  a  new  perineum. 

The  manner  of  introducing  and  fastening  the  main  sutures 
is  the  same  as  in  the  operation  for  partial  laceration.  By 
the  approximation  of  the  sides  of  the  jn-ramid  the  anterior 
border  is  doubled  up  forward  on  itself,  forming  a  ridge  on 
the  posterior  wall  of  the  vagina;  and  the  posterior  border 
is  similarly  doubled  up  backward,  forming  a  ridge  on  the 
anterior  wall  of  the  rectum. 

The  principle  on  wliich  these  simple  methods  of  repair- 
ing a  lacerated  perineum  are  based  was  introduced  by 
Lawson  Tait ;  it  has  revolutionized  the  surgical  treatment 
of  lacerated  perineum.  It  was  no  uncommon  thing  for  a 
surgeon  to  spend  an  hour  and  a  half  in  making  flaps  and 
suturing  them  in  order  to  attempt  to  repair  a  perineum,  and 
a  large  proportion  of  operations  failed.  Now  the  operation 
can  be  performed  in  ten  or  fifteen  minutes  by  an  operator 
of  average  dexterity,  with  certainty  of  success. 

There  are  few  operations  so  simple  to  perform,  but  harder 
to  describe  or  more  difficult  to  comprehend,  even  from  the 
best  descriptions.  As  a  matter  of  fact,  the  operation  must 
be  witnessed  in  order  to  be  understood. 


OPERATIONS   ON  PERINEUM,    VULVA,   AND    VAGINA.    347 

Aftcr-trcatuicnt. — An  important  detail  is  to  insist  that  the 
bladder  be  relieved  regularly  every  six  or  eight  hours  by 
the  patient's  own  efforts  or  with  a  catheter :  the  bowels 
should  be  relieved  every  day  naturally  or  with  the  help  of 
purgatives  or  an  enema. 

The  sutures  are  withdrawn  about  the  fourteenth  day; 
it  is  wise  to  keep  the  patient  absolutely  resting  three 
weeks. 

Removal  of  Urethral  Caruncle. — This  troublesome 
condition  admits  of  two  methods  of  treatment:  i.  Excision; 
2.  Destruction  by  the  cautery. 

Whichever  method  be  employed,  it  is  wiser  to  have  the 
patient  anaesthetized.  No  doubt  many  cases  have  been 
successfully  treated  under  the  use  of  local  anaesthetics,  but 
for  the  satisfactory  relief  of  this  condition  it  is,  before  all 
things,  necessary  that,  whatsoever  method  be  employed,  the 
removal  should  be  thorough. 

Instruments  required  in  addition  to  the  list  on  p.  338: 
Iris-forceps  and  scissors;  needles  and  sutures;  catheters; 
sponge-holder;  Paquelin's  cautery. 

(i)  Excision. — The  patient  is  anaesthetized  and  secured 
in  the  lithotomy  position.  The  urethral  orifice  is  well 
exposed  in  a  good  light  and  the  bladder  evacuated  by 
means  of  a  catheter.  The  bill  of  the  speculum  is  then 
introduced  into  the  vagina,  and  the  urethra  dilated  with  the 
uterine  dilators  up  to  No.  6.  The  caruncle  is  then  carefully 
dissected  from  the  muscular  layer  of  the  floor  of  the 
urethra,  and  followed  up  the  canal  until  its  limits  are 
reached,  and  snipped  off.  Useful  instruments  for  this 
purpose  are  the  delicate  forceps  and  scissors  employed  for 
operations  on  the  iris.  After  the  caruncle  is  snipped  off 
there  is  generally  free  bleeding :  this  is  easily  controlled  by 
passing  two  thin  silk  sutures  through  the  cut  edge  of  the 
urethral  mucous  membrane  and  the  free  margin  of  the 
urethral  orifice.  When  the  sutures  are  tied  the  bleeding 
ceases.       Should    any    little   vessel    still    spirt,    it    may  be 


348  DISEASES  OE   WOMEN. 

lightly  touched  with  a  narrow  point  of  an  electric  or 
I'aquelin's  cautery. 

Aflcr-tnatnioit. — Some  patients  are  able  to  micturate 
unaided  within  a  few  hours  after  the  operation  ;  in  others 
retention  lasts  for  several  days,  necessitating  the  careful 
use  of  the  catheter  thrice  each  twenty-four  hours  or  oftener. 
In  this  event  the  nurse  observes  scrupulous  cleanliness, 
always  removing  the  mucus  and  pus  which  ma)'  have 
accumulated  around  the  urethral  orifice,  before  introducing 
the  catheter.  The  method  of  keeping  the  catheter  clean 
is  described  in  Chapter  XLV.  In  passing  the  catheter  care 
should  be  taken  to  have  it  well  oiled  and  to  avoid  undue 
pressure  on  the  floor  of  the  urethra.  The  patients  recjuire 
to  keep  their  bed  for  about  seven  days. 

(2)  Destruction  by  the  Caiitay. — This  is  the  simplest 
method :  the  patient,  duly  anaesthetized,  is  arranged  as  for 
excision.  The  vulvar  structures  are  then  carefully  protected 
by  retractors  or  the  fingers  of  an  assi.stant,  and  the  caruncle 
is  thoroughly  destroyed  with  the  narrow  point  of  the 
cautery  at  a  red  heat.  Vaseline  is  then  applied  to  the 
cauterized  surface. 

The  cautery  answers  very  well  for  small  caruncles. 

The  aftcr-trcatmciit  is  the  same  as  that  described  after 
excision. 

Removal  of  the  Clitoris. — This  operation  is  necessary 
in  two  conditions :    i.  ICi^ilhelioma  ;   2.  Elephantiasis. 

Instniincnts  required  in  addition  to  the  usual  set  (p.  338) : 
Scalpel;  ha;mostatic  forceps;  Paciuclin's  cautery;  dissect- 
ing forceps. 

The  Steps  of  the  Operation. — The  patii-nt  is  ana-sthctizcd 
and  arranged  in  the  lithotoni}-  pt)sition,  the  skin  freely  in- 
cised so  as  to  include  the  diseased  area.  The  crura  of  the 
clitoris  are  then  exposed  and  detached  from  the  pubic  arch 
by  means  of  a  raspatory  or  handle  of  the  scalpel.  The 
bleeding  is  alwaj's  free,  but  the  surgeon  aims  to  secure  with 
forceps  the  dorsal  arteries  of  the  clitoris  as  soon  as  they 


OFEKATIONS   ON  PERINEUM,    VULVA,   AND    VAGINA.    349 

are  divided.  Should  the  oozing  be  free  after  the  larger 
vessels  have  been  secured,  the  application  of  a  sponge  or 
cotton-wool  compress  wrung  out  of  very  hot  water  may 
control  it.  Failing  this,  the  cut  surfaces  should  be  seared 
with  the  point  of  a  Paquelin  (or  an  electric)  cautery  at  a 
dull   red  heat. 

Occasionally  the  diseased  parts  may  be  removed  with  the 
scalpel,  and  leave  sufficient  loose  skin  to  enable  the  edges 
to  be  brought  into  apposition  by  means  of  sutures.  This 
is  very  desirable,  as  it  controls  the  oozing  and  should  be 
followed  by  immediate  union.  When  the  diseased  surface 
is  destroyed  by  the  cautery,  or  the  surrounding  tissues  are 
so  involved  that  a  wide  removal  of  skin  as  well  as  clitoris 
is  necessary,  then  the  denuded  area  is  left  to  repair  by 
granulations  and  cicatrization. 

Tumors  of  the  I/abia. — No  definite  plan  can  be  de- 
scribed to  meet  the  needs  of  every  variety  of  tumors  occur- 
ring in  this  region,  but  the  principles  involved  are  those 
which  apply  in  other  regions  of  the  body.  It  is  advisable 
to  have  the  hair  removed  from  the  part,  the  field  of  ope- 
ration washed  thoroughly  with  warm  soap  and  water,  and 
a  compress  wrung  out  of  an  antiseptic  solution  applied 
for  twelve  hours  before  the  time  fixed  for  the  operation. 
As  the  labia  are  very  vascular,  operations  on  them  are 
attended  with  free  bleeding.  It  is  always  a  great  advantage 
to  bring  the  skin-edges  together  even  when  it  is  necessary 
to  sacrifice  this  tissue  freely,  as  in  the  case  of  epithelioma 
or  melanoma.  In  applying  dressings  to  operation  wounds 
in  this  region  it  is  essential  to  arrange  them  in  such  a  way 
that  they  need  not  be  disturbed  during  micturition  or  be 
soiled  during  the  act. 

Cyst  of  Bartholin's  Gland. — The  incision  should  be 
vertical,  at  the  junction  of  the  skin  and  mucous  mem- 
brane. When  it  is  possible,  the  cyst  should  be  removed 
without  being  punctured  or  incised  ;  for  the  operation  is 
easier,  and  in  the  case  of  abscess  the  tissues  are  not  soiled 


350  DISEASES   OF   WOMEN. 

with  tlie  pus.     Hut  it  is  often  very  difficult  to  avoid  punc- 
turiujj^  a  suppurating^  cyst. 

Hcniorrliagc  is  j^cncrally  moderately  free  from  the  ven- 
ous plexus  round  about ;  this  is  especially  the  case  with  sup- 
puratini^  cysts.  In  the  deeper  portions  small  branches  of 
the  internal  pudic  artery  may  be  cut  and  require  lij^ature. 
The  slight  oozing  which  persists  is  best  controlled  by  pas.s- 
ing  three  or  four  deep  sutures  from  one  side  to  the  other ; 
each  suture  should  enter  and  leave  the  skin  3  mm.  from 
the  cut  edge,  and  should  pass  under  the  cavity  left  by  the 
removal  of  the  cyst  without  penetrating  into  it. 

Even  when  this  is  done  there  is  generally  a  little  effusion 
for  the  first  twenty-four  hours,  so  that  it  is  advisable  to 
place  a  small  drainage-tube  at  the  most  dependent  part  of 
the  wound,  and  keep  it  in  for  twelve  to  thirty-six  hours,  as 
required. 

In  addition  to  the  deep  sutures,  a  few  superficial  ones 
may  be  used  to  keep  the  wound-margins  in  accurate 
position. 

A  dressing  of  iodoform  gauze  is  applied,  and  changed 
frequently  to  avoid  urinary  contamination.  If  there  be 
much  vaginal  discharge,  a  douche  of  permanganate  of  pot- 
ash or  perchloride  of  mercury  (i  in  5000)  solution  is  ad\is- 
able  twice  or  thrice  each  day. 

Colporrhaphy  {Elytrorrhaphj). — This  term  is  applied  to 
an  operation  (of  which  there  are  many  modifications)  for 
narrowing  the  vagina  by  dissecting  away  a  portion  of  the 
mucous  membrane,  either  from  the  rectal  aspect  (posterior 
colporrhaphy)  or  from  the  vesical  aspect  of  the  vagina 
(anterior  colporrhaphy).  The  operation  is  mainly  cmploj-ed 
for  the  relief  of  severe  prolapse  of  the  uterus,  cystocele, 
and  rcctocele. 

Posterior  Colporrhaphy. — The  patient  is  secured  in 
the  lithotomy  position  and  the  vagina  thoroughly  exposed 
by  a  duck-bill  speculum.  An  elliptical  incision,  one  end 
of  the  major  axis  being  close  to  the  cervix,  the  other  near 


OPERATIONS   ON  PERINEUM,    VULVA,   AND    VAGINA.    35  I 

the  vulvar  orifice,  is  made  in  the  mucous  membrane,  taking 
care  not  to  cut  deeper  than  the  recto-vaginal  septum,  lest 
the  bowel  be  cut  open.  The  vaginal  mucous  membrane  is 
then  cautiously  dissected  off:  the  amount  to  be  removed  is 
estimated  by  the  laxity  of  the  parts  and  the  degree  of  nar- 
rowing which  the  operator  regards  as  necessary  to  meet  the 
needs  of  the  case.  After  removing  the  mucous  membrane 
and  securing  the  bleeding  vessels,  the  cut  edges  of  the  mu- 
cous membrane  are  brought  into  apposition  by  a  continuous 
silk  suture  or  interrupted  sutures  of  silkworm  gut,  wire,  or 
such  other  material  as  the  operator  thinks  well  to  employ. 

The  patient  is  kept  in  bed  for  at  least  two  weeks ;  her 
bowels  are  regulated,  and  the  bladder  should  not  be  allowed 
to  become  over-distended.  The  sutures  should  be  removed 
in  about  ten  days. 

Anterior  Colporrhaphy. — This  is  a  similar  procedure 
carried  out  on  the  anterior  vaginal  wall.  The  bladder  is 
very  liable  to  be  injured  in  dissecting  off  the  mucous  mem- 
brane, and  is  particularly  liable  to  be  punctured  when  the 
sutures  are  introduced. 

Colpo-perineorrhaphy.  —  Posterior  colporrhaphy.  is 
often  combined  with  perineorrhaphy :  all  that  is  necessary, 
in  addition  to  the  procedure  described  under  the  latter  ope- 
ration, is  to  remove  with  scissors  a  wedge-shaped  piece  of 
the  vaginal  flap,  and  then  to  bring  the  resulting  edges  of 
the  flap  together  with  fine  sutures. 


CHAPTER    XL. 

OPERATIONS   FOR   VAGINAL   FISTULA  AND  ATRESIA  OF 
THE   GENITAL  CANAL. 

In  this  chapter  the  following  fistula;  will  be  considered : 
I.  Vesico-viiginal ;  2.  Urethro-vaginal ;  3.  Urctero-vaginal ; 
4.  Utero-vcsical ;  5.  Recto-vaginal. 

The  successful  operative  treatment  of  these  condition.s 
demands  not  only  operative  dexterity  and  perseverance  on 
the  part  of  the  operator,  but  experience  and  judgment.  A 
clean  linear  cut  in  the  bladder  or  ureter  heals  spontaneously, 
but  fistulaj  which  need  the  assistance  of  the  surgeon  arc  al- 
ways the  result  of  sloughing  and  loss  of  tissue. 

Preparation  of  the  Patient. — This  consists  in  thorough  irri- 
gation of  the  vagina  and  complete  evacuation  of  the  bowels. 
The  excoriation  of  the  vulva  and  the  adjacent  parts  of  the 
thighs  heals  quickly  enough  when  the  leakage  of  urine  is 
arrested. 

Instruments  required  :  The  crutch  ;  duck-bill  speculum  ; 
vesico-vaginal  fistula  knives ;  thin  needles  in  handles  ;  silver 
wire;  fishing  gut;  dissecting-forceps ;  wire-twister;  scissors. 

Vesico-vaginal  Fistula. — In  the  majority  of  cases  the 
lithotomy  position  is  the  most  convenient,  but  special  con- 
ditions may  demand  a  dififerent  position. 

The  principle  underlying  the  treatment  of  all  fistulae  of 
mucous  canals  aj^plies  herC' — namely, 

1.  The  vix'ifying  of  the  edges  of  the  fistula; 

2.  The  careful  suturing  of  the  edges ; 

3.  Immetliate  union. 

I .  Pari)ig  the  Edges  of  the  Fistula. — This  is  effected  in  the 

352 


OPERATIONS  FOR    VAGINAL   FJSTUL.E,  ETC.        353 

following  manner  :  Access  to  the  vagina  is  obtained  by  means 
of  a  duck-bill  speculum  held  by  an  assistant.  The  margins 
of  the  fistula  arc  then  freely  pared  by  means  of  a  sharp,  deli- 
cate knife  mounted  on  a  long  handle.  These  knives  are 
usually  supplied  in  sets  of  three  or  four,  with  the  blades 
adjusted  at  different  angles  to  meet  any  difficulty  according 
to  the  position  of  the  fistula.  In  paring  the  edges  care  is 
taken  to  avoid  bruising,  but  it  is  necessary  to  thoroughly 
vivify  the  whole  circumference  of  the  fistula. 

Application  of  Sutures. — The  sutures  may  consist  of  silk 
thread,  silver  wire,  or  silkworm  gut.  Whatever  material  is 
used,  it  should  be  introduced  with  a  slender  needle  and 
should  traverse  the  muscular,  but  not  the  mucous,  coat  of 
the  bladder  or  urethra  (Fig.  102).  This  stage  affords  much 
scope  for  ingenuity  on  the  part  of  the  operator. 

When  silkworm  gut  or  silk  is  used  the  sutures  are  se- 
cured with  a  reef-knot :  when  the  silver  wire  is  used  it  is 
fastened  with  the  S-headed  twister. 

After  the  sutures  are  fastened  it  is  wise  to  test  the  wound 
to  ascertain  if  it  be  water-tight.  For  this  purpose  milk  is 
injected  into  the  bladder.  Should  any  escape  through  the 
wound,  an  additional  suture  is  inserted  at  the  situation  of 
the  leak.  If  all  be  secure,  the  bladder  and  vagina  are 
gently  irrigated  with  warm  water  and  the  patient  returned 
to  bed. 

After-treatment. — It  is  advisable  as  soon  as  the  patient  re- 
covers consciousness  to  allow  her  to  lie  on  her  side  or  even 
in  the  prone  position. 

Some  operators  prefer  to  keep  a  catheter  in  the  bladder 
for  several  days :  others  of  equal  experience  reject  this 
method  and  enjoin  the  regular  careful  use  of  the  catheter. 
It  is  important  to  keep  the  bowels  regular. 

Removal  of  Sutures. — These  may  be  withdrawn  about  the 
eighth  or  tenth  day,  and  this  is  best  effected  under  an  an- 
aesthetic. 

When  the  fistula  is  small,  its  complete  closure  may  be 
23 


354 


DISEASES   OF   WOMEN. 


effected  by  a  single  operation,  hut  in  many  cases,  especially 
wlicn  the  hole  is  hir^e,  a  small  fistula  will  remain  and  re- 
quire a  second  and  even  repeated  operations  for  its  complete 
occlusion. 

It  is  wise  to  allow  a  ^ood  interval  to  elapse  before  per- 
forming a  second  operation,  to  allow  the  wound  to  contract, 
and  the  patient  to  benefit  by  change  of  air  and  scene  after 


Fig.  I02. — Method  of  passing  the  suture  in  ihc  operation  for  vesico-vaginal  fistula 


the  confinement  to  bed.  The  misery  these  patients  suffer 
makes  them  importunate  in  regard  to  operation. 

The  most  difficult  fistuLx  to  close  are  those  situated  near 
the  vesical  orifice  of  the  urethra  and  those  near  to  or  actu- 
ally involving  the  ureteric  orifice. 

Uretero-vaginal  Fistulae. — These  often  close  spon- 
taneously; failing  this,  attempts  should  be  made  to  close 
them  by  a  plastic  operation  on  the  principles  employed  for 
the  occlusion  of  a  vesico-vacrinal  fistula.     In  some  cases 


OPERATIONS  FOR    VAGINAL   F/STULW':,   ETC.        355 

surgeons  have  removed  the  kidney  in  order  to  relieve  wo- 
men of  their  almost  insufferable  distress. 

Utero-vesical  Fistula. — This  is  very  rare,  and  in  order 
to  deal  with  it  the  surgeon  will  find  it  necessary  to  separate 
the  bladder  from  the  neck  of  the  uterus,  as  advised  in  the 
first  steps  in  the  operation  of  vaginal  hysterectomy,  in  order 
to  expose  the  vesical  portion  of  the  fistula. 

Recto-vaginal  Fistula. — This  is  a  fa;cal  fistula,  and 
when  it  complicates  grave  diseases  of  the  rectum  or  vagina, 
such  as  cancer,  sarcoma,  or  syphilitic  lesions,  operations  are 
not  admissible. 

When  the  fistula  follows  an  injury  and  persists,  it  is  treated 
on  the  same  lines  as  a  vesico-vaginal  fistula.  The  operation 
may  be  conducted  from  the  rectum  when  the  fistula  is  acces- 
sible, but  most  operators  prefer  to  carry  out  the  treatment 
through  the  vagina. 

Colpocleisis. — This  term  signifies  an  operation  for  the 
closure  of  the  vagina.  It  has  been  practised  for  the  relief 
of  incurable  forms  of  vesico-vaginal  fistul£e. 

The  principle  of  the  operation  consists  in  vivifying  the 
whole  circumference  of  the  vagina  below  the  fistula,  and 
then  bringing  the  pared  edges  into  close  apposition  by 
means  of  silver-wire  or  silkworm-gut  sutures,  on  the  same 
principle  as  that  employed  for  closing  vesico-vaginal  fistul?e. 

The  Operative  Treatment  of  Atresia  of  the  Geni- 
tal Passage. — It  will  be  necessary  to  discuss  operations 
coming  under  this  heading  in  the  following  order:  i.  Im- 
perforate hymen ;  2.  Cicatricial  union  of  the  labia ;  3.  Oc- 
clusion of  the  vagina;    4.  Occlusion  of  the  cervical  canal. 

All  these  operations  arc  undertaken  for  one  or  other,  and 
sometimes  to  effect  all  three,  of  the  following  objects :  [a) 
Evacuation  of  retained  secretion ;  (/;)  To  establish  a  per- 
manent opening ;    (r)  To  restore  the  function  of  the  parts. 

I.  Imperforate  Hymen. — It  will  be  useful  to  begin 
with  this  condition,  including  under  the  phrase  "  imperforate 
hymen  "  those  cases  in  which  the  lower  end  of  the  vagina 


35^  DISEASES   OF   WOMEN. 

is  obstructed  by  a  diaphraj^in  independent  of  the  hymen. 
(See  Chapter  V.) 

Many  of  these  patients  are  healthy  young  girls  of  fifteen 
to  twenty,  and  in  such  cases  the  surgeon  endeavors  to  fulfil 
the  three  objects  stated  above. 

Instruments  required,  in  addition  to  those  described  on 
p.  338:  retractors;  pressure-forceps;  scalpel;  catheter. 

Steps  of  the  Operation. — The  patient  is  secured  by  means 
of  the  crutch  in  the  lithotomy  position,  and  the  recesses  of 
the  vulva  well  douched.  A  catheter  is  introduced  into  the 
bladder,  and  the  septum  separating  the  vulva  and  vagina  is 
then  freely  incised.  This  is  followed  by  a  free  flow  of  dark- 
colored,  tenacious  fluid  (old  blood  mixed  with  secretions). 
As  soon  as  the  fluid  ceases  to  flow,  the  tube  of  the  douche 
or  irrigator  is  introduced,  and  the  remaining  fluid  is  freely 
washed  out  with  a  weak  solution  of  permanganate  of  potash. 
The  opening  is  lightly  stuffed  with  gauze. 

When  possible  an  endeavor  should  be  made  to  secure 
the  edges  of  the  sac  formed  by  the  distended  vagina,  bring 
them  down,  and  secure  them  to  the  edges  of  the  septum, 
the  redundant  parts  of  which  should  be  freely  cut  away. 

After-treatment. — Nothing  in  surgery  is  simpler  than  the 
evacuation  of  a  hsmatocolpos  due  to  a  thin  horizontal  sep- 
tum. Simple  as  the  operative  measure  is,  it  used  to  be  fol- 
lowed by  direful  results  from  decomposition  of  retained  se- 
cretion. It  is  in  the  highest  interests  of  the  patient  to  thor- 
oughly evacuate  the  secretion,  and  to  keep  the  cavity  well 
drained  and  regularly  irrigated  during  ten  or  fourteen  days 
following  operation.  Having  watched  the  case  safely  through 
this  stage,  it  then  becomes  necessary  to  maintain  the  patency 
of  the  orifice.  This  is  often  a  very  troublesome  perform- 
ance, and  not  infrequently  so  difficult  and  even  impossible 
of  performance  that  it  is  in  some  cases  necessary  to  pro- 
duce an  artificial  menopause  by  oophorectomy,  and  even  to 
carry  out  hystcrcctonn-. 

Cicatricial  Union  of  the  I^abia. — In  this  condition 


OPERATIONS  FOR    VAGINAL   FISTUI./E,  ETC.        357 

operative  measures  are  needed  to  remedy  defects  caused  by 
noma;  burns;  injury  during  delivery. 

When  the  cicatricial  union  follows  noma  and  burns,  it 
may  lead  to  complete  occlusion  of  the  vulvar  orifice  in  girls, 
and  produce  the  same  results  as  imperforate  hymen — 
namely,  haematocolpos.  To  remedy  this  it  is  insufficient 
merely  to  perforate  the  obstructing  septum ;  it  is  necessary 
to  dissect  away  the  cicatrix  and  endeavor  by  means  of  an 
adjustment  of  skin-flaps  to  fill  in  the  gap.  To  obtain  flaps 
for  this  purpose  the  surgeon  will  often  need  to  exercise  his 
ingenuity.  Some  may  be  obtained,  as  in  rhinoplasty,  by 
turning  down  adjacent  skin,  or  brought  from  other  regions, 
as  by  Thiersch's  method. 

When  operative  measures  are  employed  to  remedy  cica- 
tricial contractions  due  to  injury  during  labor,  they  are  un- 
dertaken often  to  restore  the  functions  of  the  part  or  to 
relieve  dyspareunia.  For  these  ends  they  are  rarely  suc- 
cessful. 

For  Occlusion  of  the  Vagina. — Under  this  heading 
will  be  considered  operations  where  the  vulva  is  naturally 
developed,  but  the  vagina  ends  in  a  cul-de-sac. 

In  these  cases  operations  may  be  demanded  to  allow  of 
the  escape  of  retained  secretion,  or  they  are  performed  to 
allow  of  the  exercise  of  the  sexual  functions  of  the  parts. 

No  definite  steps  can  be  described  to  guide  the  operator. 
Each  case  presents  difficulties  demanding  for  their  satisfac- 
tory accomplishment  much  care,  experience,  and  often  in- 
genuity on  the  part  of  the  operator. 

The  objects  to  which  the  surgeon  directs  his  attention 
are  these : 

1.  To  assure  himself  as  far  as  possible  that  the  patient 
has  a  normal  uterus  and  functional  ovaries ; 

2.  To  secure  a  passage  lined  continuously  with  mucous 
membrane  from  the  vulva  to  the  neck  of  the  uterus,  capable 
of  admitting  intercourse. 

If  in  the  course  of  the  operation  he  ascertain  that  the 


35 y  DISEASES   OF   H'OA/EX. 

uterus  is  small  aiul  ill-clcvclopcd,  ihcii  it  is  useless  to 
proceed. 

Operations  for  Atresia  of  the  Cervix. — These  are 
deinaiuied  for  the  relief  cjf  blocked  secretions.  The  condi- 
tions are  threefold  :  ha.'matometra  ;  hydrometra  ;  pyometra. 

The  object  in  such  operations  is  not  only  to  evacuate 
the  retained  blood,  secretion,  or  pus,  as  the  case  may  be, 
but  also  to  maintain  a  patent  orifice. 

In  many  cases  it  is  sufficient  to  relieve  the  strictured 
canal,  and  then  keep  the  passage  open  by  means  of  bougies. 

Experience  teaches  the  uncertainty  and  difficulty  of  the 
method,  and  the  improvement  in  surgery  has  led  some  ope- 
rators to  carry  out  abdominal  hysterectomy  in  these  cases ; 
it  is  more  radical,  but  is  freer  from  risks  of  septic  peri- 
tonitis, than  the  traditional  methods  of  operating  through 
the  vauina. 


CHAPTER    XLI. 

OPERATIONS   ON   THE   UTERUS. 

DILATATION  OF  THE  CERVICAL  CANAL 
OF  THE  UTERUS;  CURETTING;  VAGI- 
NAL   MYOMECTOMY. 

Dilatation. — It  may  be  necessary  to  dilate  the  cervical 
canal  for  the  following  purposes:  i.  To  remove  retained 
products  of  conception ;  2.  Curettage ;  3.  For  Dysmenor- 
rhoea;  4.  Removal  of  a  polypus;  5.  Diagnostic  purposes 
in  suspected  cases  of  polypus  or  cancer  of  the  body  of  the 
uterus. 

For  whichever  of  the  above  purposes  the  procedure  may 
be  necessaiy,  the  principle  of  effecting  it  is  the  same,  but 
there  is  a  slight  difference  in  detail. 

In  addition  to  the  usual  gynaecological  instruments  (see 
p.  338)  it  is  necessary  to  be  furnished  with  dilators  and  a 
curette  (scraper). 

Uterine  Dilators. — There  are  many  varieties  of  dilators ; 
the  set  we  find  most  useful  were  designed  by  Dr.  W.  H. 
Fenton  (Fig.  103).  Of  these,  ten  make  a  set:  each  consists 
of  a  curved  metal  rod  made  of  copper  and  electro  plated 
with  silver.  The  advantasfe  of  using  metal  dilators  is  that 
they  can  be  immersed  in  the  sterilizer.  Each  dilator  is  30 
cm.  (12  in.)  in  length,  but  differs  in  thickness  at  each  end, 
so  that  after  introducing  the  narrow  end  into  the  uterine 
cavity  the  operator  reverses  the  instrument  for  the  succeed- 
ing number.  For  instance,  the  dilator  in  Fig.  103  at  its 
upper  end  has  a  diameter  of  10  mm.  and  at  its  lower  end  a 
diameter  of  1 1  mm.    The  degree  of  graduation  is  represented 

359 


360  DISEASES   UE    11' OMEN. 

in  the  drawing,  and  the  actual  diameter  of  a  particular  dilator 
is  also  given.  In  using  these  instruments  they  need  to  be 
thoroughly  lubricated.  It  is  also  well  to  have  a  distinctive 
mark,  so  that  the  operator  can  easily  distinguish  the  smaller 
from  the  larger  end.  There  are  many  ways  of  doing  this : 
in  the  set  represented  the  higher  number  is  distinguished  by 
a  metal  collar.  These  instruments  are  very  useful  for  dilat- 
ing the  urethra  when  it  is  necessary  to  explore  the  interior 
of  the  bladder. 

The  Curette  (or  Scraper). — This  term  is  applied  to  an 
instrument  employed  for  scraping  the  cavity  of  the  uterus 
or  its  cervical  canal.  There  arc  several  varieties  of  curettes  : 
some  are  shaped  Hke  a  spoon  with  sharp  edges,  whilst  others 
are  ring-shaped  with  thin  edges  (Fig.  104).  They  are  fur- 
nished with  handles  so  that  they  may  be  effectively  used. 
Some  curettes  are  made  hollow,  and  are  connected  with  an 
irrigator  by  means  of  india-rubber  tubing,  so  that  a  stream 
of  sterilized  water  or  an  antiseptic  solution  issues  from  the 
instrument  and  flushes  the  uterine  cavity  whilst  the  scrap- 
ing is  in  progress.  Flushing  curettes  are  very  inconvenient 
instruments  to  handle. 

The  principle  of  the  curette  is  this :  All  soft  processes 
and  diseased  tracts  of  mucous  membrane  or  retained  pieces 
of  placenta  and  decidua  are  easily  detached  by  it,  whilst  its 
edge  is  not  sharp  enough  to  damage  the  underlj'ing  mus- 
cular wall  of  the  uterus  when  the  implement  is  used  with 
due  care  and  gentleness. 

The  Steps  of  the  Operation. — The  patient  is  deepl}'  anaes- 
thetized with  ether  and  secured  in  the  lithotomy  position  by 
means  of  the  crutch.  The  vagina  is  then  douched  with 
warm  water,  and  the  bill  of  the  speculum  introduced  into 
the  vulvar  orifice.  The  anterior  lip  of  the  cer\'ix  is  secured 
with  a  volsella,  so  as  to  be  under  the  control  of  the  opera- 
tor. The  uterine  sound  is  then  gently  introduced  to  furnish 
information  as  to  the  length  and  direction  of  the  uterine 
cavity. 


OTEKATIONS   ON   THE    UTERUS. 


361 


The  dilators  arc  then  introduced  in  the  following  manner  : 
They  lie  in  their  proper  order  in  a  vessel  of  warm  water  (or 
weak  antiseptic  solution)  close  to  the  hand,  or,  preferably, 
they  are  taken  up  in  turn  by  the  nurse  and  dipped  in  vase- 


FiG.  103. — Fenton'5  dilator.  The  median 
circles  represent  the  actual  diameter  of  the 
smallest  and  largest  dilator. 


Fig.  104. — Curettes. 


line  or  a  vessel  containing  glycerin  and  perchloride  of  mer- 
cury (i  in  2000),  and  then  introduced  into  the  cervical  canal 
with  the  right  hand,  whilst  the  operator  makes  counter- 
traction  by  firmly  grasping  the  volsclla,  which  is  fixed  to 


362  DISEASES   OF   WOMEN. 

the  cervix,  with  the  left.  The  early  numbers  usually  pass 
easily  so  long  as  they  are  well  anointed  and  introduced  into 
the  axis  of  the  uterine  cavity. 

The  rapidity  and  dej^ree  of  dilatation  vary  with  the  neces- 
sity of  the  case.  Thus,  when  the  operation  is  undertaken 
to  remove  retained  products  of  conception,  the  softened  cer- 
vical canal  dilates  very  easily,  and  th«  dilatation  is  carried  on 
until  the  canal  is  large  enough  to  admit  the  index  finger, 
and  permit  thorough  exploration  of  the  uterine  cavity. 
(The  finger  will  follow  No.    16  or   18.) 

For  diagnostic  purposes  in  cases  of  suspected  polypus  it 
is  wise  to  dilate  sufficiently  to  admit  the  finger ;  in  this  way 
exact  information  as  to  the  seat,  size,  and  condition  of  the 
tumor  is  obtained. 

When  needed  for  suspected  disease  (cancerous  or  other- 
wise) of  the  endometrium,  dilatation  to  No.  10  or  12  is 
sufficient,  as  this  allows  the  introduction  of  the  curette  and 
abstraction  of  fragments,  and  even  complete  curettage  of 
the  uterine  cavity. 

For  dysmenorrhoea,  the  dilatation  is  rarely  carried  beyond 
No.  8.  In  many  cases  of  uterine  polypus  occurring  in  single 
and  sterile  married  women  the  cervical  tissues  do  not  easily 
yield  to  the  dilator,  and  great  care  is  necessary  to  avoid  ex- 
tensive laceration  of  the  cervical  tissues  in  the  vicinity  of 
the  internal  os. 

It  is  sometimes  an  advantage  to  secure  the  neck  of  the 
uterus  with  two  volselkne — one  on  the  anterior  and  one  on 
the  posterior  lip. 

There  are  two  opposite  conditions  to  be  borne  in  mind 
when  using  dilators :  A  soft  and  yielding  cervix,  as  in 
patients  who  have  recently  aborted  or  who  have  a  can- 
cerous uterus,  readily  admits  the  instruments,  but  is  easily 
perforated  by  the  sound  or  thin  dilators.  A  firm,  unyield- 
ing cervix  easily  lacerates,  and  the  exercise  of  undue  force 
during  the  introduction  will  cause  the  instrument  to  perfor- 
ate the   uterine  wall  or  tear  the  lower  part  of  the  cervix 


OPERATIONS   ON  THE    UTERUS.  363 

from  the  upper  in  a  circular  direction.  Unless  the  direction 
of  the  uterine  canal  be  carefully  observed,  a  false  passage  is 
apt  to  be  made,  burrowing  into  the  uterine  tissue  or  into 
the  mesometrium. 

After  the  canal  has  been  dilated  to  the  requisite  size,  and 
the  operator  has  met  the  requirement  of  the  case  by  abstrac- 
tion of  fragments  of  placenta  or  a  polypus,  etc.,  he  thor- 
oughly douches  the  cavity  with  warm  water;  then  dries  it 
with  pledgets  of  cotton  wool  on  a  uterine  probe,  and  applies 
iodized  phenol,  iodine,  or  any  application  he  deems  necessary 
to  the  endometrium.  In  cases  where  the  oozing  is  free,  the 
cavity  may  be  plugged  with  sterilized  gauze,  or  gauze  im- 
pregnated with  iodoform,  aristol,  or  other  drugs  in  fashion. 
The  vagina  is  tamponed,  the  surrounding  parts  are  dried, 
and  the  patient  returned  to  bed. 

After-treatment. — This  is  very  simple.  In  twenty-four 
hours  all  tampons  and  plugs  are  withdrawn  and  a  warm 
vaginal  douche  administered  twice  daily. 

In  the  simplest  case  it  is  wise  to  keep  the  patient  confined 
to  her  bed  ten  days  :  in  other  cases  no  rule  can  be  laid 
down ;  it  must  be  decided  by  individual  experience. 

Dangers. — Dilatation  of  the  cervical  canal  is  the  sim- 
plest of  all  gynaecological  operations,  and  if  conducted  with 
scrupulous  care  and  cleanliness  should  have  but  one  risk — 
namely,  that  of  the  anaesthetic.  It  is,  however,  occasionally 
a  source  of  grave  danger  and  death.  Fatal  results  have 
been  due  to  the  following  causes : 

1.  Perforation  of  the  uterus  with  the  sound,  curette,  or 
dilator,  and  fatal  peritonitis. 

2.  Septic  endometritis  spreading  into  the  Fallopian  tubes. 

3.  Pelvic  cellulitis  secondary  to  laceration  of  the  cervix. 

4.  Rupture  of  purulent  collections  in  the  Fallopian  tubes 
(pyosalpinx)  or  ovaries  (ovarian  abscess). 

5.  Should  dilatation  be  incautiously  advised  and  the  uterus 
be  gravid,  abortion  would  be  the  almost  inevitable  conse- 
quence. 


364  DISEASES   OF   WOMEN. 

Vaginal  Myomectomy. — Under  this  hcaclin^^  will  be 
dcscribctl  tlic  various  operations  for  the  removal  of  niyomata 
from  the  cervical  canal  and  cavity  of  the  uterus. 

Instruments  required  in  addition  to  those  enumerated  on 
page  338:  scissors,  scalpel,  bull-dog  volsella,  h.-emostatic 
forceps,  sponge-holders. 

Steps  of  the  Operation. — These  vary  considerably  accord- 
ing to  the  size,  character,  and  position  of  the  tumors.  It 
will  be  convenient  to  describe  the  simplest  condition,  and 
then  proceed  gradually  to  those  that  may  offer  very  great 
difficulty. 

The  patient  is  secured  in  the  lithotomy  position  by  means 
of  the  crutch :  the  vagina  is  thoroughl)'  douched,  and  the 
cemx  exposed  by  a  duck-bill  speculum. 

A  Pedunculated  Myoma  {Polypus)  protruding  from  the 
Cervix. — In  such  a  case  the  operator  carefully  examines  the 
polypus  with  the  view  of  ascertaining,  if  possible,  the  point 
where  the  pedicle  is  connected  with  the  uterus :  he  should 
also  satisfy  himself  that  the  uterus  is  not  partially  inverted 
(see  p.  157).  With  a  stout  pair  of  scissors  the  j^edicle  is 
snipped  through  and  the  tumor  detached :  then  the  fore- 
finger is  introduced  to  be  certain  that  there  are  no  other 
polypi.  The  parts  are  then  thoroughly  irrigated  and  dried 
with  cotton-wool  on'  the  uterine  probe :  tampons  impreg- 
nated with  a  mild  antiseptic  reagent  (liquid  or  powder)  are 
inserted  into  the  vagina,  and  the  patient  returned  to  bed. 

After-treatment. — The  tampons  are  removed  in  twelve 
hours  and  the  vagina  douched  twice  daily.  If  there  has 
been  much  bleeding  prior  to  operation,  and  this  has  pro- 
duced marked  anajmia,  some  mild  preparation  of  iron  may 
be  prescribed.  Convalescence  at  the  end  of  two  weeks  is 
the  rule. 

A  Sessile  Myoma  Protrudes  at  the  Ccr^'ix. — When  such  a 
tumor  does  not  exceed  the  size  of  a  bantam's  Qgg,  it  may 
be  dealt  with  in  the  following  way  : 

The   cervical  canal   is   dilated   until   it   easily  admits  the 


OPERATIONS   ON   THE    UTERUS.  365 

finger :  this  enables  the  operator  to  determine  the  size  and 
position  of  the  tumor.  With  a  scalpel  he  divides  the  mucous 
membrane  overlying  the  tumor,  and  with  his  finger  or  a 
raspatory  shells  the  tumor  out  of  its  capsule  up  to  its  base. 
With  a  stout  bull-dog  volsella  (Fig.  8)  the  tumor  is  seized 
close  up  to  its  base,  inside  the  capsule,  and  then  he  gently 
and  cautiously  rotates  the  volsella,  and  at  the  same  time 
drags  upon  it :  this  twists  the  myoma,  and  after  two  or 
three  complete  turns  it  is  dragged  out  of  its  bed. 

The  uterus  is  flushed  with  water  at  105°  F.,  then  care- 
fully dried  with  cotton-wool  on  a  sponge-holder  or  forceps. 
When  there  is  free  oozing  the  cavity  is  plugged  with  anti- 
septic or  sterilized  gauze. 

The  chief  danger  in  this  operation  is  seizing  the  tissue  of 
the  uterine  wall  instead  of  the  tumor.  Free  bleeding,  and 
even  fatal  peritonitis,  may  follow  a  tear  through  the  wall 
of  the  uterus. 

When  the  myoma  is  septic,  the  cavity  of  the  uterus  should 
be  thoroughly  curetted. 

Occasionally  it  happens  that  after  reflecting  the  capsule 
of  a  myoma  it  cannot  be  extracted  without  the  exercise  of 
unjustifiable  force.  It  is  then  advisable  to  leave  it  for  a  few 
days  until  the  uterine  contractions  extrude  it  somewhat 
from  its  bed.  Then  a  renewed  attempt  will  usually  be 
successful.  There  is  always  great  danger  of  bleeding 
and  sepsis,  and  such  cases  are  nearly  always  attended 
with  anxiety. 

Sessile  and  Peditncnlated  Uterine  Myoniata  zvitk  an  Undi- 
lated  Cervical  Canal. — When  the  symptoms  indicate  the 
probable  presence  of  a  submucous  myoma  the  operator 
dilates  the  cervical  canal  and  explores  the  uterine  cavity 
with  his  finger.  On  detecting  a  myoma  he  then  determines 
its  size,  seat,  and  character.  When  it  is  small,  he  pro- 
ceeds according  to  the  instructions  detailed  in  the  two 
preceding  sections. 

It  occasionally  happens  that  he  finds  himself  face  to  face 


3^6  DISEASES   OF   WOMEN. 

with  one  or  other  of  these  conditions:  i.  A  hir^^c  pedun- 
culated myoma;  2.  A  large  sessile  myoma  with  a  broad 
base. 

In  the  first  example  it  is  easy  to  detach  the  tumor  from 
its  pedicle  by  rotation,  but  the  difficulty  will  be  met  with  in  its 
"  delivery."  In  the  second  example  there  will  be  difficulty 
in  detaching  as  well  as  in  delivering  it. 

This  brings  us  to  the  consideration  of  the  important  ques- 
tion :  How  large  a  tumor  may  be  safely  and  expeditiously 
delivered  by  vaginal  myomectomy  ? 

We  will  relate  our  own  practice  in  this  matter :  With  a 
yielding  cervix  the  cervical  canal  can  be  readily  and  without 
risk  dilated  up  to  No.  20  (a  diameter  of  25  mm.),  and  this 
will  allow  of  the  extraction  of  a  myoma  of  the  size  of  a 
bantam's  o.^^.  Submucous  myomata  are  often  ovoid.  Wiien 
the  tumor  exceeds  these  dimensions  its  detachment  and  de- 
livery may  be  facilitated  by  free  bilateral  division  of  the 
cervix  up  to  the  vaginal  reflection  :  should  the  bleeding  be 
free,  the  uterine  artery  may  be  secured  at  the  end  of  each 
incision  by  means  of  a  silk  ligature  and  an  aneur}'sm  needle. 
Myomata  with  a  diameter  of  5  cm.  may  be  detached  and  ex- 
tracted in  this  manner.  The  divided  surfaces  of  the  cervix 
are  easily  brought  into  apposition  and  secured  with  silk- 
worm-gut sutures. 

When  a  myoma  equals  in  size  a  foetal  head  it  is  possible 
to  remove  it  through  the  vagina  by  the  method  known  as 
"  morcellement."  The  cervical  canal  is  dilated,  and  then 
the  cervix  is  split  on  each  side  with  scissors :  the  uterine 
arteries  are  then  secured  with  ligatures.  The  division  of 
the  cervix  gives  free  access  to  the  uterine  cavity.  Some- 
times it  is  more  useful  to  turn  the  bladder  off  the  cervix,  as 
in  the  first  stages  of  vaginal  hysterectomy ;  then  ligature 
the  uterine  arteries  and  split  the  anterior  wall  of  the  cervix 
as  high  as  the  peritoneal  reflection. 

The  next  step  of  the  operation  consists  in  freely  incising 
the  capsule  of  the  tumor ;  then,  after  enucleating  it  to  its 


OPERATIONS   ON   THE    UTERUS.  367 

base,  the  operator  proceeds  to  remove  it  piecemeal  by- 
means  of  scissors  and  stout  volselLx. 

Myomectomy  by  "  morcellement "  is  greatly  in  favor  in 
France.  In  this  country  it  is  not  widely  practised.  The 
custom  of  the  leading  gynaecologists  in  this  country  is 
to  limit  vaginal  myomectomy  to  tumors  not  exceeding  a 
diameter  of  5  or  6  cm. — roughly  the  dimensions  of  the 
patient's  fist.  When  a  myoma  exceeds  these  dimensions 
abdominal  hysterectomy  is  the  safer  method. 

The  dangers  of  vaginal  myomectomy  are — hemorrhage ; 
damage  to  the  walls  of  the  uterus  ;  inversion  of  the  uterus ; 
septicaemia. 

Some  gynaecologists  employ  an  antiquated  instrument 
called  the  "  ecraseur  "  to  divide  the  stalks  of  pedunculated 
submucous  myomata.  In  a  few  years  it  is  to  be  hoped  that 
this  instrument  will  only  be  seen  in  museums. 


CHAPTER    XLII. 

OPERATIONS  ON  THE  UTERUS  (Continued). 

TRACHELORRHAPHY; AMPUTATION  OF  THE 
CERVIX;  VAGINAL  HYSTERECTOMY;  COL- 
POTOMY. 

Trachelorrhaphy. — This  name  is  applied  to  an  opera- 
tion for  the  repair  of  lacerations  of  the  cervix  uteri. 

Preparation  of  the  Patient. — This  is  very  important  in 
order  to  secure  a  successful  result.  It  is  advisable  that  the 
patient  should  be  kept  in  bed  for  a  week  or  ten  days  in 
order  to  allow  of  regular  vaginal  douching  to  reduce  the 
congestion  of  the  exposed  mucous  membrane  of  the  cer- 
vical canal.  In  some  cases  it  may  be  necessary  to  make 
local  applications  of  iodized  phenol,  or  to  curette  the  endo- 
metrium. 

Instruments  required  in  addition  to  those  enumerated  on 
p.  338 :  Scalpel  ;  reversible  tcnacula-forceps :  needles  and 
silkworm  gut ;   dissecting-forceps. 

The  Steps  of  the  Operation. — The  patient  is  anaesthetized 
and  fixed  in  the  lithotomy  position,  and  the  cervix  well 
exposed  by  means  of  the  duck-bill  speculum.  The  cervix 
is  then  secured  by  the  reversible  tenacula-forceps,  as  shown 
in  Fig.  105.  By  means  of  scalpel  and  forceps  the  operator 
dissects  flaps  from  the  exposed  surfaces  of  the  cervix,  taking 
care  to  preserve  a  narrow  strip  of  mucous  membrane  in  the 
middle  line  (Fig.  106),  which  will  form  the  lining  for  the  new 
cervical  canal  when  the  flaps  are  approximated.  Whilst 
the  surfaces  are  being  vivified  there  is  usually  free  oozing : 
this  is  useful,  as  it  serves  to  deplete  the  cervix  and  dimjn- 
ishes  its  volume. 

3C8 


OPERATIONS   ON  THE    UTERUS. 


369 


The  cervical  flaps  arc  now  brout^ht  together  and  retained 
in  apposition  by  the  reversible  tenacula-forceps  (Fig.  loC): 
this  instrument  enables  the  operator  to  manipulate  the  cer- 
vix during  the  introduction  of  the  sutures.  For  this  pur- 
pose a  slightly  curved  needle  on  a  handle  is  very  convenient. 
The  sutures  may  be  of  silver  wire,  silkworm  gut,  or  silk,  se- 


FiG.  105. — Trachelorrhaphy  :  Stage  i.     The  cervix  seized  with  the  reversible  tenacula- 
forceps  (A.  E,  G.). 

cured  with  shot  and  coil  (Fig.  107).    Silkworm-gut  sutures 
secured  by  knots  are  quite  sufficient. 

When  the  sutures  are  fastened,  a  sound  is  passed  into  the 
uterus  to  ensure  that  the  cervical  canal  is  free.     The  parts 
are  then  carefully  dried  and  the  vagina  lightly  stuffed  with 
iodoform  gauze. 
24 


370 


DISEASES   OE   WOMEN. 


xXftcr-trcattih'iit. — This  ccmsists  in  kctpin^f  the  vagina  as 
dry  as  possible.     When  there  is  dischari^'e,  and  irrigation  is 

retjuired,  then  the  vagina  should 
be  carefully  dried  after  each 
douche. 

Sutures  are  removed  on  the 
tenth  day  ;  for  this  puqjose  the 
patient  is  j^laced  in  the  lithot- 
omy position,  facing  a  good  light : 
with  very  nervous  patients  an 
ana-sthetic  is  necessary. 

Amputation  of  the  Cervix 
Uteri. — Amputation  of  the  neck 
of  the  uterus  is  performed  for 
epithelioma,  cancer,  and  hyper- 
trophic elongation. 

The  methods  of  performing 
this  operation  have  been  greatly 
modified  and  simplified :  it  will 
therefore  be  advantageous  to  de- 
part from  the  usual  custom  of 
describing  every  modification  that  has  been  introduced,  and 
give  an  account  of  ,the  principles  of  the  operation.  It  is 
necessary  to  point  out  that  vaginal  hysterectomy  is  so  rapidly 
coming  into  favor  that  amputation  of  the  cervix  will,  in  the 
majority  of  cases,  be  superseded  by  this  more  thorough 
operation. 

Instruments  required  in  addition  to  the  list  on  p.  338  : 
Retractors;  catheter;  needles  on  handles  ;  haemostatic  for- 
ceps ;  electric  or  Paquelin's  cautery ;  dissecting-forceps ; 
sterilized  silk  ligatures ;  six  (antiseptic)  sponges. 

Steps  of  the  Opcratiivi. — The  cervix  is  thoroughly  exposed 
by  the  introduction  of  the  bill  of  a  large  speculum  :  with  the 
sound  the  operator  determines  the  position  of  the  cervical 
canal  and  estimates  the  mobility  of  the  uterus ;  by  means  of 
the  vesical  sound  the  precise  relation  of  the  bladder  to  the 


Fig.  106. — Trachelorrhaphy  :  Stage  2 
Dissection  of  flaps  (A.  E.  G.). 


OPERATIONS   ON   THE    UTERUS. 


371 


cervix  is  ascertained.  The  cervix  is  firmly  t^rasped  with  a 
stout  volsella  and  drawn  down  :  with  a  scalpel  the  surijeon 
transversely  divides  the  mucous  membrane  on  the  anterior 
wall  of  the  cervix  as  hit^h  above  the  cancer  as  the  bladder 
permits;  the  assistant  keeps  him  informed  of  the  position  of 
the  bladder  by  retaining  the  sound  in  the  lowest  part  of  the 


Fig.   107. — Trachelorrhaphy  :    Stage  3.     Closure  of  the  cervical  flaps  and  method  of 
securing  sutures  (A.  E.  G.). 

vesical  cavity.  Having  divided  the  mucous  membrane,  the 
bladder  is  easily  detached  from  the  cervix  by  the  handle 
of  the  scalpel. 

The  knife  is  then  carried  through  the  mucous  membrane 
on  the  sides  and  posterior  aspect  of  the  cervix.  The  next 
step  is  to  secure  the  uterine  arteries  as  they  run  on  to  the 
sides  of  the  cervix  near  the  spot  where  the  vaginal  mucous 
membrane  is  reflected  on  to  it.     When  the  bladSer  is  de- 


372  niSEA:siL:i  oj-  humkx. 

tachcd  and  held  apart  from  the  cervix  by  a  retractor,  whilst 
the  cervix  is  drawn  down  by  the  volsella,  the  artery  may  be 
seen  (Fig.  lo8),  and  is  easily  secured  by  a  silk  thread  con- 
veyed around  it  by  an  aneurysm  needle.  It  is  well  to  secure 
it  with  two  threads,  and  as  close  to  the  cervix  as  possible,  in 
order  to  avoid  the  ureter. 

Having  secured  the  artery  on  each  side,  the  cervix  may 
be  amputated  with  a  scalpel,  with  scissors,  or  by  means  of 
the  galvanic  or  Paquelin's  cautery.  When  the  uterine 
arteries  are  deliberately  exposed  and  secured  there  is  no 
bleeding  from  the  stump,  but  a  small  artery  here  and  there 
in  the  cut  edge  of  the  vaginal  mucous  membrane  may  re- 
quire to  be  seized  with  haemostatic  forceps  or  ligatured. 

The  vagina  is  then  douched,  dried,  and  tamponed,  and 
the  patient  returned  to  bed. 

The  after-treatment  is  simple :  opiates  are  sometimes  re- 
quired. The  tampons  are  removed  in  twenty-four  hours,  and 
the  vagina  douched  twMce  daily.  The  catheter  is  used  every 
eight  hours  unless  the  patient  can  void  her  urine  unaided : 
this  is  always  an  advantage.     Convalescence  is  usually  rapid. 

Dangers. — In  judiciously  selected  cases  the  operation 
is  one  of  the  safest  in  surger}^  The  pitfalls  are  these:  The 
bladder  may  be  injui:ed  in  the  process  of  separating  it  from 
the  cervix.  If  the  arteries  are  tied  at  a  distance  from  the 
uterus,  the  ureters  are  apt  to  be  included  in  the  ligature. 
When  the  posterior  incision  is  carried  too  far  back,  the  rec- 
tum may  be  damaged  and  cause  a  temporary  faecal  fistula. 
If  the  peritoneum  is  accidentally  incised  and  the  recto-vagi- 
nal fossa  opened,  then  the  incision  should  be  closed.  Pelvic 
cellulitis  and  peritonitis  may  arise  if  aseptic  precautions  are 
not  rigidly  carried  out.  Hemorrhage  may  occur  from  slip- 
ping of  an  ill-applied  ligature. 

Amputation  of  the  Hypertrophied  Cervix. — In  this 
condition  the  surgeon  is  not  content  with  cutting  off  the 
redundant  portion  of  the  cervix,  but  employs  certain  plastic 
procedures. 


OPERATIONS    ON   THE    UTERUS.  373- 

The  patient  is  prepared  and  arran^^cd  as  when  the  opera- 
tion is  performed  for  cancer.  The  incisions  are  made  in 
such  a  way  as  to  allow  flaps  to  be  fashioned  from  the  over- 
lying mucous  membrane.  When  the  tissue  of  the  cervix 
proper  is  cut  through,  there  is  always  very  free  bleeding 
and  the  spouting  vessels  are  not  easy  to  secure  with  forceps 
or  ligature.  '  It  is  preferable  to  touch  them  with  a  Paquelin 
cautery  at  a  dull-red  heat.  The  flaps  of  mucous  membrane 
are  now  brought  over  the  cut  face  of  the  cervix  and  secured 
with  sutures  to  the  margin  of  the  mucous  membrane  lining 
the  cervical  canal. 

This  manoeuvre  is  necessary,  as  it  prevents  undue  retrac- 
tion and  contraction  of  the  cervix,  which  may  ultimately 
lead  to  atresia  of  the  cervical  canal,  with  various  unpleasant 
consequences. 

Vagfinal  Hysterectomy. — This  signifies  the  removal 
of  the  uterus  (and  sometimes  the  ovaries  and  Fallopian 
tubes  with  it)  through  the  vagina.  It  is  mainly  performed 
for  cancer  of  the  cervical  canal  and  cancer  of  the  body  of 
the  uterus,  but  it  may  be  necessar}'-  to  remove  the  uterus 
by  this  route  in  such  conditions  as  sarcoma  of  the  uterus ; 
chronic  intractable  endometritis ;  uterine  myomata ;  and  in- 
tractable procidentia  in  older  women. 

The  instruments  required  are  the  same  as  those  employed 
for  amputation  of  the  cervix. 

The  Steps  of  the  Operation. — The  patient,  duly  anesthe- 
tized, is  fixed  i«  the  lithotomy  position  facing  a  window. 
The  surgeon,  seated  at  a  convenient  level,  introduces  the 
bill  of  a  large  speculum  into  the  vagina.  The  cervix  is 
then  seized  with  a  stout  volsella  and  drawn  down.  The 
assistant  by  means  of  a  sound  in  the  bladder  keeps  the 
operator  informed  as  to  the  precise  relation  of  that  viscus  to 
the  cervix. 

The  mucous  membrane  on  the  anterior  aspect  of  the 
cervix  is  then  transversely  divided  with  a  scalpel,  taking 
care  not  to  injure  the  bladder.    The  operator  then  separates 


374 


DISEASES   OF   WOMEN. 


the  bladder  from  the  cervix  by  means  of  the  handle  of  the 
scalpel  (Fii^.  io8). 

The  incision  is  next  prolonged  arountl  the  cervix,  and  by 
means  of  scissors  an  opening  is  made  into  the  recto-vaginal 
fossa  through  the  posterior  cul-de-sac  of  the  vagina ;  a 
sponge  is  then  inserted  to  restrain  as  well  as  protect  the 
intestines. 

The   operator  now  deals  with  the  broad   ligaments.     A 


Fig.  io8. — First  stage  of  vaginal  hysterectomy,    it  shows  the  l)laddcr  reflected  from  the 
cervix  and  the  position  of  the  uterine  arteries. 

pedicle-needle  (or  a  curved  needle)  armed  with  stout  silk  is 
made  to  transfix  the  tissues  at  the  side  of  the  uterus,  kcej)- 
ing  quite  close  to  the  cervix  in  order  to  avoid  the  ureter. 
This  ligature  is  firmly  tied,  and  will  include  the  uterine 
artery  as  it  passes  from  the  mesometrium  to  the  sitle  of  the 
uterus  (Fig.   io8) ;  the  tissue  between  it  and  the  cervix  is 


OPERATIONS   ON   THE    UTERUS.  375 

divided  with  scissors,  care  being  taken  to  leave  sufficient 
tissue  to  prevent  the  ligature  from  slipping.  Tlie  same 
manoiuvre  is  carried  out  on  the  opposite  side.  The  effect 
of  this  is  to  free  the  uterus  considerably,  and  to  enable  it  to 
be  well  drawn  down  by  the  volsella.  A  double  ligature  is 
now  carried  through  the  remaining  section  of  the  mesome- 
trium  and  the  two  halves  are  tied :  the  upper  ligature  encir- 
cles the  Fallopian  tube,  ovarian  vessels,  and  ligament,  as 
well  as  the  round  ligament  of  the  uterus ;  the  tissues  be- 
tween the  ligatures  and  uterus  are  divided,  and  the  fundus 
of  the  uterus  now  comes  easily  into  the  vagina  and  permits 
the  ligatures  to  be  readily  applied  to  the  opposite  side. 

If  the  silk  threads  have  been  properly  secured,  there  is, 
as  a  rule,  no  bleeding.  Should  any  vessel  be  observed 
spouting,  it  is  readily  seized  with  forceps  and  ligatured. 
The  surgeon  examines  the  ovaries  and  tubes,  and  should 
they  show  signs  of  disease  they  can  be  easily  removed. 
After  counting  the  sponges  the  vagina  is  then  irrigated  with 
warm  water,  and  two  or  three  long  strips  of  gauze  inserted, 
which  serve  to  prevent  the  intestine  being  forced  into  the 
vagina  during  vomiting  or  straining,  and  at  the  same  time 
act  as  an  efficient  drain. 

The  ligatures  are  left  long,  and  their  ends,  knotted  to- 
gether, lie  in  the  vagina.  The  ligatures  which  are  applied 
to  the  upper  parts  of  the  broad  ligaments  may  be  cut  short 
and  allowed  to  remain  as  after  ovariotomy :  if  aseptic,  they 
cause  no  trouble  and  convalescence  is  considerably  short- 
ened. 

On  the  whole,  we  think  the  best  results  follow  the  use  of 
ligatures,  but  some  operators  dispense  entirely  with  ligatures 
and  clamp  the  broad  ligaments  with  long  slender  forceps, 
and  then  cut  the  uterus  away  from  its  connections.  These 
forceps  are  left  ///  situ  forty-eight  hours  and  are  then  re- 
moved. 

Colpotomy. — h^xpcrience  acquired  in  the  performance 
of  vaginal  hysterectomy  has  taught  surgeons  that  the  intra- 


37<3  DISEASES   OE   WOMEN. 

pciitoiio;il  relations  of  the  uterus  and  its  appendages  may 
be  exploreti,  with  reasonable  safet\-,  tlu()U<^di  an  incision  in 
the   vaginal  cul-de-sac. 

When  the  incision  is  made  posterior  to  the  cervix,  it  is 
called  posterior  colpotomy.  Wiien  the  operation  is  carried 
out  anterior  to  the  cervix,  between  it  and  the  bladder,  it  is 
called  anterior  colpotomy. 

Colpotomy  is  employed  for  the  following  purpo.ses  :  For 
retroflexion  of  the  uterus;  small  tumors  of  the  ovary;  for 
tubal  pregnancy;  for  tubal  disease;  and  for  prolapse  of  the 
ovary. 

Instruments  required  in  addition  to  the  list  on  p.  338 : 
Scalpels  ;  haemostatic  forceps  ;  dissecting-forceps  ;  needles 
in  handles  ;  silk  ;  silkworm-gut ;  needles  ;  volsellae. 

Anterior  Colpotomy. — The  patient  is  placed  in  the 
lithotomy  position  and  the  bill  of  the  speculum  introduced 
into  the  vagina ;  the  cervix  is  then  drawn  down  with  a  vol- 
sella  and  a  sound  is  introduced  into  the  bladder.  The  vag- 
inal mucous  membrane  anterior  to  the  cervnx  is  incised 
transversely,  taking  care  not  to  injure  the  bladder.  (Some 
operators  make  this  incision  vertical.)  With  the  handle  of 
the  scalpel  the  bladder  is  detached  from  the  cervix,  as  in 
the  first  steps  of  a  vaginal  hysterectomy.  The  peritoneum 
as  it  passes  from  the  uterus  to  the  bladder  is  di\ided,  and 
the  operator's  fingers  are  now  in  the  utero-vesical  pouch. 
This  enables  him  to  ascertain  accurately  the  position  of  the 
uterus  and  the  coexistence  or  otherwise  of  ovarian  enlarge- 
ment or  distention  of  the  tubes. 

When  an  ovaiy  is  prolapsed  or  obviously  diseased  it  may 
be  withdrawn  through  the  incision,  its  pedicle  ligatured, 
and  the  organ  removed.  This  would  be  a  vaginal  oopho- 
rectomy. Retroflexion  of  the  uterus  is  dealt  with  thus :  A 
sound  is  introduced  into  the  uterus,  Avhich  is  then  straight- 
ened and  anteverted.  A  curved  needle  armed  with  a  silk 
ligature  is  passed  through  the  anterior  aspect  of  the  body 
of  the  uterus;  the  ends  of  the  suture  are  carried  through 


OPERATIONS   ON   THE    UTERUS.  377 

the  mar^^ins  of  the  vaginal  incision  :  when  this  hgature  is 
fastened  it  maintains  the  uterus  in  position  and  at  the  same 
time  closes  the  vaginal  incision.  The  adhesions  which 
form  in  consequence  of  these  proceedings  are  supposed  to 
retain  the  uterus  in  its  rectified  position. 

In  some  cases  where  the  uterus  is  mobile  in  its  flexed 
condition  it  is  unnecessary  to  open  the  utero-vesical  cul- 
de-sac.  The  fixation  of  the  uterus  thus  becomes  an 
extra-peritoneal  proceeding,  but  then  the  operator  is 
unable  to  ascertain  the  true  condition  of  the  ovaries  and 
tubes. 

Some  gynaecologists  have  advocated  the  fixation  of  the 
uterus  to  the  bladder.  This  is,  however,  a  method  not  to 
be  recommended. 

The  subsequent  treatment  is  very  simple :  the  bowels  are 
carefully  regulated,  and  the  vagina  douched  twice  daily 
with  a  weak  solution  of  permanganate  of  potash. 

The  advantage  claimed  for  this  operation  over  abdominal 
hysteropexy  (ventro-fixation)  is  that  it  is  safer  and  avoids 
the  chance  of  a  yielding  cicatrix. 

Noble,  in  writing  of  the  results  of  vaginal  fixation  of  the 
uterus,  states  :  "  Over  one-fourth  of  the  pregnancies  follow- 
ing this  operation  have  ended  in  abortions,  and  the  recent 
literature  is  burdened  with  reports  of  versions,  artificial  ex- 
tractions, forceps  operations,  craniotomies,  and  Porro  opera- 
tions, so  that  I  feel  that,  following  its  originators,  we  must 
consider  it  as  condemned  by  its  results,  and  as  an  unjusti- 
fiable operation  in  the  case  of  women  of  childbearing  age  " 
(1896). 

Posterior  Colpotomy. — This  is  an  extremely  simple 
proceeding.  The  field  of  operation  is  exposed  as  for  anterior 
colpotomy,  and  the  recto-vaginal  fossa  is  reached  through 
a  transverse  incision  in  the  posterior  cul-de-sac.  The  sur- 
geon is  then  able  to  ascertain  the  condition  of  the  uterus 
and  the  ovaries  and  tubes,  Through  such  an  incision  he  is 
able  to  break  down  adhesions  which  ma)'  fi.K  the  uterus,  or 


37S  DISEASES   01  -WOMEN. 

remove  a  prolapsed  ovary,  or  a  small  ovarian  tumor,  or  a 
gravid  tube  in  its  very  early  stages. 

In  cases  of  fluid  effusions,  such  as  exist  in  po.stcrif>r 
serous  perimetritis,  or  extravasation  of  blood  following  intra- 
peritoneal rupture  of  a  gravid  tube,  or  tubal  abortion,  this 
method  of  exploring  the  recesses  of  the  pelvis  is  regarded 
as  being  safer  than  an  incision  through  the  linea  alba. 


CHAPTER    XLIir. 

GROUP  II.— ABDOMINAL  OPERATIONS. 

In  this  c^roup  the  following  operative  procedures  will  be 
described:  i.  Cccliotomy ;  2.  Ovariotomy;  3.  Enucleation 
of  sessile  pelvic  cysts  and  tumors  ;  4.  Oophorectomy ;  5. 
Operations  for  tubal  pregnancy  ;  6.  Hysterectomy ;  7.  Hys- 
teropexy ;    8.  Shortening  the  round  ligaments. 

CCELIOTOMY   (LAPAROTOMY). 

When  the  surgeon  opens  the  abdomen  for  the  purpose 
of  removing  a  tumor  growing  in  a  viscus,  the  operation  re- 
ceives a  specific  name  according  to  the  organ  concerned, 
such  as  ovariotomy,  nephrectomy,  splenectomy,  and  so 
forth.  In  very  many  cases  the  conditions  preclude  an  exact 
diagnosis,  and  the  operation  of  making  an  opening  into  the 
belly  cavity  is  styled  coeliotomy,  but  it  may  become  a  colec- 
tomy, or  an  oophorectomy,  etc.  There  are  many  condi- 
tions in  the  abdomen  requiring  treatment  through  an  incis- 
ion in  its  walls  which  do  not  readily  lend  themselves  to  a 
single  expressive  term — for  instance,  omental  tumors,  cysts 
of  the  mesenteiy,  and  echinococcus  colonies — so  that  it 
becomes  convenient  to  use  the  term  coeliotomy  as  express- 
ing an  operation  by  which  the  belly  is  opened  by  a  cut. 

In  all  the  operations  described  in  this  section  the  import- 
ant step  is  to  gain  entrance  into  the  cffilom  (or  peritoneal 
cavity)  by  an  incision  in  its  parictcs,  most  frequently  through 
the  linea  alba  ;  it  will  therefore  be  convenient  to  describe  the 
mode  of  preparation  of  the  patient,  the  requisite  instruments, 
and  the  manner  of  carr}'ing  it  out. 

Preparation  of  t/ic  Patient.— It  is  advantageous  to  keep 

379 


380  DISEASES   OF   WOMEN. 

the  patient  confined  to  bed  for  two  or  three  days  prccedinj^ 
the  operation.  She  should  be  prepared  as  for  any  other 
serious  surgical  proceeding.  The  rectum  should  be  emp- 
tied, preferably  by  enemata,  and  the  patient  should  abstain 
from  food  at  least  six  hours  before  the  operation  :  this  di- 
minishes the  chances  of  vomiting.  The  nurse  shaves  the 
pubes  and  washes  the  abdomen  with  warm  soap  and  water. 
Si.x  hours  previous  to  the  operation  the  lower  part  of  the 
belly  is  swathed  in  a  compress  soaked  with  an  antiseptic 
solution  (such  as  carbolic  acid  i  in  60  or  perchloride  of 
mercury  i  in  2000).  Immediately  before  the  patient  is 
placed  on  the  table  the  bladder  should  be  emptied  naturally 
or  by  means  of  a  catheter.  In  all  abdominal  operations  it 
is  a  great  advantage  to  employ  nurses  who  have  had  spe- 
cial training  in  "  abdominal  nursing." 

Instriunents. — All  instruments  employed  in  performing 
coeliotomy  should  be  constructed  of  metal,  as  this  enables 
them  to  be  thoroughly  sterilized  by  boiling.  The  follow- 
ing are  always  necessary:  2  scalpels ;  12  haemostatic  for- 
ceps ;  2  dissecting-forceps ;  2  retractors ;  needles ;  silk ; 
catgut ;  silkworm  gut ;  24  cotton-wool  dabs  and  2  flat 
sponges ;  2  sponge-holders. 

All  sponges  and  instruments  should  be  counted  and  the 
number  written  down  before  the  operation  is  begun. 

Instruments  should  be  immersed  in  hot  water.  Sponges 
should  be  washed  in  water  (at  100°  F.)  during  the  operation. 

Suture  and  I^igature  Material.— The  three  most 
useful  materials  at  present  employed  in  abdominal  surgery 
are  silk,  catgut,  and  silkworm  gut. 

(i)  Silk  Thread. — This  material  has  a  wide  range  of  useful- 
ness, as  it  is  employed  to  secure  pedicles,  for  the  ligature  of 
vessels,  and  for  sutures.  Silk  may  be  easily  sterilized,  either 
by  prolonged  soaking  in  antiseptic  solutions  or  by  boiling. 
It  is  convenient  to  wind  the  thread  on  a  glass  spool,  boil  it 
in  the  sterilizer  for  twenty  minutes,  and  then  preserve  it  in 
a  solution  of  carbolic  acid  (i  in  20).     Sets  of  these  .spools 


ABDOMINAL    OPERATIONS.  38 1 

provided  with  silks  of  three  degrees  of  thickness  answer 
most  purposes — a  stout  plaited  silk  for  ordinary  pedicles  ; 
a  thinner  silk  for  vessels,  omental  adhesions,  or  sutures  for 
the  skin ;  and  fine  silk  for  securing  torn  edges  of  bowel. 

Silkivorni  Gut  {Salmon  Gut). — This  material  is  obtained 
from  the  bodies  of  silkworms  when  about  to  spin.  It  is 
obtainable  in  large  quantities  from  fishing-tackle  manufac- 
turers, as  it  has  long  been  employed  by  anglers.  Silkworm 
gut  is  an  admirable  material  for  sutures,  and  is  not  injured 
by  boiling.  It  is  preserved  for  use  in  carbolic-acid  solutions 
(i  in  20). 

Catgut. — A  very  useful  and  easily  absorbable  ligature 
material  prepared  from  the  intestinal  wall  of  sheep.  The 
great  difficulty  is  to  obtain  it  free  from  germs,  because  im- 
mersion in  hot  water  softens  and  quickly  destroys  it. 

A  method  of  sterilizing  catgut  by  steam  has  been  devised  ; 
after  rendering  it  aseptic  it  is  wound  on  glass  spools  and 
kept  in  a  sublimate  solution. 

Although  catgut  has  many  drawbacks,  it  is  the  only 
material  yet  devised  which  can  be  left  in  the  wounds  to  be 
quickly  destroyed  by  the  tissues. 

Sponges  and  their  Substitutes. — Nothing  is  so  con- 
venient for  removing  blood  from  a  wound  as  sponges : 
their  absorbent  powers  and  softness  are  excellent,  but  it  is 
difficult  to  sterilize  them,  and  their  price  makes  it  necessary 
to  use  them  for  a  series  of  operations.  Sponges  when  new 
are  prepared  in  the  following  way :  They  are  well  beaten 
to  shake  out  the  dust,  then  immersed  several  hours  in 
water  containing  hydrochloric  acid  (5  c.cm.  to  the  litre) ; 
they  are  then  washed  thoroughly  in  hot  water  and  kept  in 
a  solution  of  carbolic  acid  (i  in  40).  After  sponges  have 
been  used  they  are  thoroughly  washed  in  water,  then 
immersed  in  water  to  which  some  carbonate  of  soda  is 
added.  They  arc  again  washed  in  running  water,  and 
preserved  in  carbolic-acid  solution  (l  in  40)  or  dried  and 
kept  in  air-tight  glass  jars. 


382  DISEASJ-IS    Ul-    noMEiW 

Any  spoiiL^c  which  has  been  in  contact  with  a  septic 
Wduntl  or  pus  should  be  promptly  cast  into  the  fne. 

Tile  hi^h  price  of  spon^^^s  and  tlifficulty  in  their  steriliza- 
tion have  induced  surgeons  to  employ  pads  of  cotton-wool 
or  gauze  moistened  with  sterilized  water  or  antiseptic 
solutions. 

Another  excellent  substitute  is  prepared  by  making  bags 
of  gauze  and  then  filling  them  with  absorbent  cotton-wool. 
These,  often  called  cotton-wool  or  gauze  sponges  (or  dabs)^ 
may  be  easily  sterilized  in  the  hot-air  sterilizer  (oven)  or 
may  be  impregnated  with  antiseptic  drugs. 

The  Table. — In  the  majority  of  cases  a  table  such  as 
is  employed  in  ordinary  surgical  operations  answers  every 
purpose.  It  is  necessary  to  place  beneath  the  patient  a 
strip  of  waterproof  material  covered  by  a  towel. 

In  some  cases,  in  dealing  with  small  cysts  adherent  to 
the  floor  of  the  pelvis  or  in  searching  for  bleeding  points, 
it  is  a  great  advantage  to  place  the  patient  in  the  Trendelen- 
burg position,  in  which  the  pelvis  is  raised  and  the  head 
and  shoulders  lowered ;  this  allows  the  intestines  to  fall 
toward  the  diaphragm  and  leaves  the  pelvis  unen- 
cumbered. 

Anaesthesia. — Sortie  surgeons  prefer  chloroform  or  the 
A.  C.  E.  mixture  ;  others  employ  ether.  Ether  administered 
by  a  skilful  anaesthetist  is  the  safest  agent  yet  discovered 
for  prolonged  anaesthesia. 

The  Abdominal  Incision. — The  patient  being  com- 
pletely unconscious,  the  operiitor,  with  his  assistant  oppo- 
site him,  divides  the  skin  and  fat  in  the  middle  line  of  the 
belly,  between  the  umbilicus  and  the  pubes,  for  a  space  of 
7  cm.  This  incision  should  reach  to  the  aponeurotic  sheath 
of  the  rectus  :  any  vessels  that  bleed  freely  require  seizing 
with  hnjmo.static  forceps.  The  linea  alba  is  then  divided, 
but,  as  it  is  very  narrow  in  this  situation,  the  sheath  of  the 
right  or  left  rectus  muscle  is  usually  opened.  Keeping  in 
the  middle  line,  the  posterior  layer  of  the  sheath  is  divided 


ABDOMINAL    OPERATIONS.  383 

and  the  subperitoneal  fat  (which  sometimes  resembles 
omentum)  is  reached;  in  thin  subjects  this  is  so  small  in 
amount  that  it  is  scarcely  recognizable  and  the  peritoneum 
is  at  once  exposed.  In  order  to  incise  the  peritoneum  with- 
out damaging  the  tumor,  cyst,  or  intestine,  a  fold  of  the 
membrane  is  picked  up  with  forceps  and  cautiously  pricked 
with  the  point  of  a  scalpel ;  air  rushes  in,  destroys  the 
vacuum,  and  generally  produces  a  space  between  the  cyst 
(or  intestines)  and  the  belly-wall :  the  surgeon  then  intro- 
duces his  finger  and  divides  the  peritoneum  to  an  extent 
equal  to  the  incision  in  the  skin. 

It  is  important  to  remember  that  the  bladder  is  some- 
times pushed  upward  by  tumors  and  lies  in  the  subperito- 
neal tissue  above  the  pubes :  it  is  then  apt  to  be  cut. 

On  entering  the  ccelom  (peritoneal  cavity)  the  surgeon 
introduces  his  hand  and  proceeds  to  ascertain  the  nature 
of  any  morbid  condition  that  he  sees  or  feels ;  or  he  evac- 
uates free  fluid,  blood  or  pus,  which  may  be  present.  Oc- 
casionally he  finds  that  attempts  to  remove  a  tumor  would 
be  futile  or  end  in  immediate  disaster  to  the  patient; 
then  he  desists  and  closes  the  wound,  and  the  procedure 
is  classed  as  an  exploratory  coeliotomy.  Should  a  re- 
movable tumor,  such  as  an  ovarian  cyst,  an  echinococ- 
cus  colony  of  the  omentum,  or  the  like,  be  found,  it  is 
removed. 

The  recesses  of  the  pelvis  are  then  carefully  sponged  in 
order  to  remove  fluid,  blood,  or  pus ;  the  sponges  and  for- 
ceps are  counted  and  preparations  made  to  suture  the 
incision. 

Closure  of  the  Wound. — This  consists  in  suturing 
each  layer  separately.  The  peritoneum  is  first  secured 
by  a  continuous  suture  of  fine  silk.  The  sheath  of  the 
rectus  is  then  brought  together  by  interrupted  sutures  of 
silkworm  gut.  Lastly,  the  skin  is  secured  by  interrupted 
or  continuous  sutures  of  silk  or  other  material  according  to 
the  fancy  of  the   operator.     The  great  advantage  of  this 


3S4  DISEASES   OE   WOMEN. 

triple  »ii-tliO({  \s  that  it  minimizes  the  risk  of  a  yielding  cica- 
trix and  obviates  the  use  of  an  abdominal  belt. 

Dressing. — This  should  be  very  simple.  A  fold  of 
sterilized  gauze  or  cyanide  gauze,  covered  with  two  or 
three  pads  of  cotton-wool  or  gamgee  tissue,  retained  in 
position  by  a  flannel  binder  fastened  with  safety-pins,  is 
sufficient. 

Irrigation. — When  the  coelom  (peritoneal  cavity)  con- 
tains free  blood,  pus,  f;ecal  matter,  etc.  previous  to  or 
during  the  performance  of  coeliotomy,  such  fluids  are  most 
expeditiously  removed  by  thorough  irrigation  with  water 
at  a  temperature  of  110°  F.  The  precise  method  mat- 
ters but  little.  In  well-appointed  operating  theatres  an 
apparatus  for  irrigating  the  belly  is  certain  to  be  present. 
In  private  practice  much  depends  on  the  ingenuity  of  the 
surgeon.  A  simple  and  very  efficient  irrigator  may  be 
made  by  inserting  a  long  piece  of  india-rubber  tubing  in  a 
large  jug  filled  with  water:  on  exhausting  the  air  from  the 
tube  and  elevating  the  jug,  the  water  will  issue  in  a  steady 
stream  from  the  tube,  and  its  force  can  be  regulated  by 
raising  or  lowering  the  jug.  When  no  tube  is  at  hand,  the 
water  may  be  poured  into  the  belly  direct  from  the  jug. 
In  order  to  irrigate  the  coelom  the  patient  is  turned  a  little 
to  one  side,  and  the  waterproof  on  which  the  patient  lies 
may  be  arranged  to  conduct  the  water  as  it  escapes  from 
the  belly  into  a  receptacle  under  the  table.  The  irrigation 
is  continued  until  the  water  comes  away  clear,  care  being 
taken  that  the  inflowing  stream  is  directed  into  the  iliac 
fossa;  and  the  recesses  of  the  pelvis.  As  soon  as  the  out- 
flowing stream  is  clean,  the  water  retained  in  the  pelvis,  the 
iliac  fossae,  and  in  the  neighborhood  is  quickly  soaked  up 
with  sponges. 

Plain  ivatcr  that  has  been  boiled  and  allowed  to  cool  to  the 
requisite  teniperatnre  is  the  safest  viedin>n  for  peritoneal 
irrii^atiou. 

Drainage. — After  the  removal  of  an  adherent  tumor  or 


ABDOMINAL    OPERATIONS.  385 

uterine  appcndafjes  blood  may  ooze  from  a  number  of 
points  too  small  or  inaccessible  to  permit  the  application 
of  ligatures.  In  such  circumstances  it  is  sometimes  desir- 
able to  insert  a  drain-tube.  When  peritoneal  drainage  was 
introduced  glass  tubes  were  used,  but  india-rubber  tubes 
are  more  satisfactory,  as  they  admit  of  being  cut  to  any 
length,  and  are  less  liable  to  damage  the  viscera  with  which 
they  may  come  in  contact. 

The  tube  should  reach  to  the  floor  of  the  recto-vaginal 
fossa,  whilst  its  upper  end  projects  from  the  lower  angle 
of  the  wound:  its  sides  should  be  perforated  The  cuta- 
neous orifice  is  surrounded  by  absorbent  dressing  to  receive 
the  escaping  fluid.  As  a  rule,  there  is  at  first  a  free  escape 
of  blood  or  blood-stained  serum,  and  the  dressing  requires 
frequent  changing  :  at  the  end  of  twenty-four  hours  it  rapidly 
diminishes.  It  is  impossible  to  frame  definite  rules  in  re- 
gard to  the  removal  of  the  tube,  as  so  much  depends  on 
the  nature  of  the  case,  but,  as  a  rule,  it  may  be  discarded  at 
the  end  of  the  second  day. 

Drainage  is  rarely  necessary  after  ovariotomy :  it  is  fre- 
quently needed  after  the  removal  of  a  firmly  adherent 
pyosalpinx. 

TJie  Mikulicz  Drain. — In  1886,  Mikulicz  of  Cracow  de- 
scribed a  method  of  draining  the  pelvic  cavity  by  means 
of  antiseptic  gauze.  A  bag  is  made  of  gauze ;  to  the  bot- 
tom of  this  bag  a  double  silk  thread  is  attached.  The  bag 
is  introduced  into  the  bed  of  the  tumor  in  the  pelvic  cavity, 
and  is  then  stuffed  with  strips  of  iodoform  gauze.  It  is  an 
advantage  to  insert  a  drain-tube  in  the  middle  of  the  bag 
and  stuff  the  gauze  around  it.  The  gauze  is  quickly  infil- 
trated with  the  infused  fluids  which  slowly  ooze  through  it, 
and  escape  at  the  free  end  into  the  dressing,  which  needs  fre- 
quent changing  (thrice  in  twenty-four  hours).  As  the  ooz- 
ing diminishes,  pieces  of  the  packing  are  slowly  with- 
drawn, and  at  last  the  bag  is  removed  by  means  of  the 
thread. 

25 


386  DISEASES   OF   WOMEN. 

It  is  difficult  to  decide  when  to  remove  a  drain  of  this 
sort :  it  should  not  be  disturbed  for  five  days,  but  may  re- 
main without  detriment  fourteen  days.  In  this  way  the 
gauze  acts  as  a  haemostatic  plug  as  well  as  a  drain. 

Peritoneal  drains  of  this  kind  are,  fortunately,  rarely 
necessary. 


CHAPTER   XLIV. 
OVARIOTOMY    AND    OOPHORECTOMY. 

OVARIOTOMY. 

Ovariotomy  signifies  the  removal  through  an  incision  in 
the  abdominal  wall  of  tumors  and  cysts  of  the  ovary  and 
parovarium. 

The  preparation  of  the  patient  is  the  same  as  that  de- 
scribed under  Coeliotomy,  and  the  additional  instruments 
required  are — ovariotomy  trocar ;  pedicle-needles  and  silk  ; 
pedicle-forceps. 

TJlc  Ovariotomy  Trocar. — Very  many  ovarian  cysts  are 
filled  with  thin  fluid  which  will  easily  flow  along  a  narrow 
tube,  and  as  the  cyst-contents  sometimes  amount  to  many 
quarts  or  even  gallons,  it  is  a  point  in  the  operation  to  con- 
duct this  fluid  into  a  receptacle.     The  ovariotomy  trocar  is 


Fig.  109. — Ovariotomy  trocar. 

designed  for  this  purpose.  It  is  constructed  so  that  it  has 
a  cutting  edge  which  will  enable  it  to  be  thrust  through 
a  stout  cyst-wall :  this  cutting  edge,  shaped  like  the  point 
of  a  quill  pen,  is  ensheathed  in  a  sliding  barrel  moved  by 
a  mounted  thumb-pece,  so  that  it  can  be  protected  at  the 
wish  of  the  operator.  On  the  sides  of  the  instrument  tlicre 
are  two  spring  hooks  for  retaining  the  instrument  in  posi- 
tion after  its  point  has  penetrated  the  cyst-wall.     The  trocar 

387 


388 


D  IS /-.ASKS   OF    U'OMEJV. 


is  fitted  to  a  metre  and  a  half  (about  five  feet)  of  iiulia- 
rubbcr  tubin<^.  The  mechanism  of  this  comphcated  instru- 
ment should  be  carefully  studied  by  those  proposing;  to  use 
it.  These  trocars  are  very  clumsy,  aiul  unless  in  constant 
use  work  stiffly  and  easily  get  out  of  order  (Figs.  109  and 
no). 

Pcdiclc-nccdlc. — This  instrument  is  designed  to  carry  the 
ligature  through  the  pedicle  of  the  tumor.  The  stem  of 
the  needle  is  about  15  cm.  long,  and  is  composed  of  nickeled 
steel  adjusted  to  a  metal  handle  (Fig.  iii).  The  stem  is 
curved  toward  the  end,  which  should  be  bluntly  pointed. 
Near  the  free  end  it  is  perforated  by  two  lioles,  one  behind 


Fig.  1 10. — Ovariotomy  trocar  with  its  point  guarded. 

the  other ;  each  should  be  capable  of  easily  accommodating 
the  thickest  ligature  silk. 

As  a  matter  of  fact,  any  needle  capable  of  carrying  the 
ligature  will  serve  the  purpose  of  a  pedicle-needle,  but  the 
needle  represented  possesses  many  advantages  which  an 
operator  will  realize  as  soon  as  he  begins  to  acquire 
experience. 

Spongc-Jioldcrs. — "Sponges  on  sticks"  are  undesirable 
in  abdominal  operations.  It  is  useful  to  employ  instruments 
in  which  sponges  or  cotton-wool  or  gauze  dabs  can  be  easily 
mounted.  A  useful  form  of  holder  is  shown  in  Fig.  112. 
It  is  an  ovum  forceps :  the  opposed  sides  of  the  fenestrated 
blades  are  devoid  of  serrations.  The  handles  are  furnished 
with  clips.  These  holders  can  be  put  to  many  useful  pur- 
poses besides  holding  sponges  :  they  are  easily  sterilized. 


OVARIOTOMY  AND    OOPHORECTOMY. 


3S9 


Steps  of  the  Operation. — As  soon  as  the  operator  enters 
the  ccelom  (peritoneal  cavity)  and   recognizes  the  bluish- 


i 


\ 


Fig.  III. — Pedicle-needle.  Fig.  iic— Sponge-holder. 

gray,  glistening  surface  of  an   ovarian  cyst,  he  inserts  his 
hand  and  passes  it  over  the  wall  of  the  tumor  to  ascertain 


390  DISEASES   OF   WOMEN. 

the  presence  or  absence  of  adhesions.  Instead  of  a  typical 
ovarian  cyst,  he  may  find  a  soHd  tumor  or  an  enlarged 
uterus ;  secondary  nodules  may  exist  on  the  peritoneum 
and  indicate  a  malignant  tumor,  or  adhesions  may  be  so 
strong  and  so  numerous  that  it  will  be  undesirable  to  con- 
tinue the  operation. 

It  is  of  the  highest  importance  to  be  satisfied  as  to  the 
nature  of  the  tumor  before  proceeding  further:  to  plunge 
a  trocar  into  a  pregnant  uterus  or  a  uterine  myoma  is  an 
accident  sure  to  involve  the  operator  in  anxious  difficulty. 

Emptyings;  the  Cyst. — F'eeling  satisfied  that  the  tumor  con- 
tains fluid,  is  not  connected  with  the  uterus,  and  is  removable, 
the  operator  proceeds  to  tap  it.  The  trocar  is  thrust  into 
the  cyst,  and  the  fluid  rushes  through  it  and  is  conducted 
by  the  tubing  into  the  receptacle  under  the  table.  As  the 
cyst  collapses,  the  trocar  is  rendered  harmless  by  sheathing 
it ;  the  cyst-wall  is  seized  with  forceps  and  drawn  into  the 
spring  clips  on  the  side  of  the  trocar,  and  as  the  cyst 
empties  it  is  gently  withdrawn  through  the  incision,  whilst 
the  assistant  keeps  the  belly- wall  in  apposition  with  the 
cyst  by  gentle  pressure  until  the  pedicle  is  reached.  Empty- 
ing the  cyst  is  not  always  so  simple.  The  fluid  is  some- 
times viscid  like  jelly,'  or  in  the  case  of  dermoids  resembles 
paste.  Then  it  is  necessary  to  make  a  free  opening  into 
the  tumor  and  remove  its  contents  with  the  hand.  It  is 
occasionally  necessary',  in  multilocular  cysts  containing  clear 
fluid,  to  introduce  the  fingers,  or  even  the  hand,  to  break 
down  secondary  loculi,  in  order  to  facilitate  the  extraction 
of  the  cyst-wall  through  a  small  incision.  When  the  tumor 
is  suspected  to  be  a  dermoid,  and  in  all  cases  where  it  is 
scarcely  larger  than  a  cocoanut,  it  is  more  prudent  not  to 
tap,  but  enlarge  the  incision  and  withdraw  it  entire. 

Adlicsioiis. — Large  portions  of  omentum  may  require  de- 
tachment, transfixion,  and  ligature  with  thin  .sterilized  silk 
to  arrest  the  bleeding.  Intestinal  adhesions  require  care 
and  patience :  sometimes  the  separation  may  be  effected  by 


OVARIOTOMY  AND    OdPHOKECTOMY.  39 1 

gently  wiping  with  a  sponge.  Adhesion  to  the  peritoneum 
in  the  pelvis  is  often  a  source  of  great  difficulty,  and  care 
must  be  taken  not  to  damage  the  ureters  or  larg-e  vessels. 
such  as  the  vena  cava  and  the  iliac  veins. 

Adhesions  to  the  bladder  are  rare  and  require  great  care  ; 
it  is  wise  to  introduce  a  sound  into  the  bladder  whilst  sepa- 
rating it  from  the  cyst. 

The  Pedicle. — When  the  tumor  is  withdrawn  from  the 
belly  the  pedicle  is  usually  easily  recognized  ;  the  Fallopian 
tube  serves  as  an  excellent  guide  to  it.  The  pedicle  con- 
sists of  the  Fallopian  tube  and  adjacent  parts  of  the  meso- 
metrium  containing  the  ovarian  artery,  pampiniform  plexus 
of  veins,  lymphatics,  nei"ves,  and  the  ovarian  ligament. 
When  the  constituents  of  the  pedicle  are  unobscured  by 
adhesions  the  round  ligament  of  the  uterus  is  easily  seen 
and  need  not  be  included  in  the  ligature. 

In  transfixing  the  pedicle  the  aim  should  be  to  pierce  the 
mesometrium  at  a  spot  where  there  are  no  large  veins,  and 
tie  the  structures  in  two  bundles,  so  that  the  inner  contain 
the  Fallopian  tube,  a  fold  of  the  mesometrium,  and  occa- 
sionally the  round  ligament  of  the  uterus,  whilst  the  outer 
consists  of  the  ovarian  ligament,  veins,  the  ovarian  artery, 
and  a  larger  fold  of  peritoneum  than  the  inner  half. 

Pedicles  differ  greatly :  they  may  be  long  and  thin  or 
short  and  broad.  Long,  thin  pedicles  are  easily  managed. 
The  assistant  gently  supports  the  tumor  whilst  the  operator 
spreads  the  tissues  with  his  thumb  and  fore  finger,  and  trans- 
fixes them  with  the  pedicle-needle  armed  with  a  long  piece 
of  silk.  The  loop  of  silk  is  seized  on  the  opposite  side  and 
the  needle  withdrawn.  During  the  transfixion  care  must 
be  taken  not  to  prick  the  bowel  with  the  needle.  The  loop 
of  silk  is  cut  so  that  two  pieces  of  silk  thread  lie  in  the 
pedicle.  The  proper  ends  of  the  threads  are  now  secured, 
and  each  is  firmly  tied  in  a  reef  knot:  for  greater  security 
the  two  ends  of  the  inner  thread  are  brought  around  the 
pedicle  and  tied  again,  so  as  to  thoroughly  secure  the  vessels. 


392  DISEASES   OF   WOMEN. 

After  the  operator  has  gained  some  experience  in  this 
simple  mode  of  tyinf^  the  pedicle  he  may  then,  if  he  thinks 
it  desirable,  practise  other  methods. 

After  securely  applying  the  ligature,  the  tumor  is  removed 
by  snipping  through  the  tissues  on  the  distal  side  of  the 
ligature  with  scissors.  Care  must  be  taken  not  to  cut  too 
near  the  silk  or  the  stump  will  slip  through  the  ligature ; 
on  the  other  hand,  too  much  tissue  should  not  be  left  be- 
hind. The  stump  is  seized  on  each  side  by  pressure-for- 
ceps, and  examined  to  see  that  the  vessels  in  it  are  secure ; 
it  is  then  allowed  to  retreat  into  the  abdomen.  Should  it 
commence  to  bleed,  it  must  be  retransfixed  and  tied  below 
the  original  ligature. 

Occasionally  a  broad,  short  pedicle  will  contain  so  much 
tissue  that  it  will  be  necessary  to  tie  it  with  three  threads. 
To  do  this  the  pedicle  is  transfixed  with  the  silk,  the  loop 
is  divided,  and  the  two  threads  arc  interlocked.  The  outer 
thread  is  tied  as  usual.  The  needle  is  refilled  with  a  single 
ligature  and  transfixion  performed.  The  needle  is  then 
unthreaded,  and  the  untied  end  of  the  silk  belonging  to  the 
first  ligature  is  passed  into  the  eye  of  the  needle,  which  is 
then  withdrawn.  The  second  ligature,  before  it  is  tied, 
must  be  interlocked-  with  the  third  thread.  When  the 
threads  are  tied  they  will  hold  the  tissues  firmly. 

It  is  impossible  to  frame  absolute  rules  for  ligaturing  the 
pedicle.  In  this,  as  in  all  departments  of  surgery,  common 
sense  must  be  exercised,  and  at  the  present  day,  when  ova- 
riotomy is  practised  so  widely,  no  one  would  think  of  per- 
forming this  operation  without  assisting  at  or  watching  its 
actual  performance  by  an  experienced  surgeon. 

Having  satisfied  himself  that  the  pedicle  is  secure,  the 
surgeon  examines  the  opposite  ovar}',  and  if  obviously  dis- 
eased he  removes  it,  securing  its  pedicle  in  the  way  just 
described. 

He  then  proceeds  to  remove  an)'  blood  or  fluid  from  the 
recesses  of  the  pelvis  by  means  of  careful  sponging.    Whilst 


OVARIOTOMY  AND    OOPHORECTOMY.  393 

employed  in  this  way  he   gives   instruction    to   have   the 
sponges  and  instruments  counted. 

When  the  operator  Hmits  the  number  of  sponges  to  six, 
he  can  easily  have  them  displayed  before  him.  He  then 
proceeds  to  suture  the  wound  in  the  manner  described  on 
page  383. 

Sessile  Cysts. — It  occasionally  happens  that  the  sur- 
geon exposes  a  cyst  in  the  pelvis  through  an  abdominal 
incision,  and,  after  tapping  it,  finds  he  cannot  withdraw  the 
cyst-wall  from  the  pelvis. 

Sessile  cysts  of  this  kind  are  removed  by  what  is  known 
as  enucleation.  The  peritoneum  overlying  the  cyst  is  cau- 
tiously torn  through  with  forceps  until  the  cyst-wall  is  ex- 
posed ;  then  by  means  of  the  fore  finger  the  surgeon  pro- 
ceeds to  shell  the  cyst  out  of  its  bed,  taking  care  not  to  tear 
the  capsule  or  any  large  vein  in  its  wall :  it  is  also  necessary 
to  exercise  the  greatest  care  to  avoid  injury  to  the  ureter. 
It  is  not  uncommon,  after  enucleating  a  cyst  in  this  way,  to 
find  a  ureter  lying  at  the  bottom  of  the  recess. 

When  the  enucleation  is  complete,  the  operator  carefully 
examines  the  walls  and  secures  oozing  vessels  and  ligatures 
them.  The  edges  of  the  capsule  are  then  brought  to  the 
margins  of  the  abdominal  wound  and  secured  with  sutures 
to  the  peritoneum.  An  india-rubber  drainage-tube  is  then 
inserted,  the  abdominal  incision  closed  in  the  usual  way, 
and  the  wound  is  dressed. 

The  capsule  of  a  sessile  cyst  requiring  treatment  of  this 
character  is  formed  by  divaricated  layers  of  the  mesomet- 
rium  (broad  ligament). 

Enucleation  is  needed  for — 

{ci)  Papillomatous  cysts  and  cysts  of  Gartner's  duct 
burrowing  deeply  between   the   layers  of  tiie 
mesometrium  ; 
{b^  Myomata  of  the  mesometrium  ; 
{c)  Very  large  examples  of  hydrosalpinx  and  pyo- 
salpinx ; 


394  DISEASES   OF   WOMEN. 

{</)  Some  ovarian  cysts,  especially  suppurating  der- 
moids ; 
(i)  Tubal  pregnancy  in  the  mesometric  stage. 

Enucleation  is  usually  accompanied  by  more  loss  of  blood 
than  simple  ovariotomy,  and  the  prolonged  manipulation 
is  often  responsible  for  severe  shock. 

Incomplete  Ovariotomy. — The  surgeon  may  start  on 
an  operation,  and  after  opening  the  abdomen  may  find  many 
adhesions,  yet  feel  that  the  removal  of  the  tumor  is  possible. 
He  sets  to  work,  overcomes  many  of  the  difficulties,  then 
suddenly  finds  such  extensive  and  firm  adhesions  to  im- 
portant structures  at  the  floor  of  the  pelvis  that  he 
deems  it  imprudent  to  proceed.  In  such  a  case  he  evac- 
uates the  contents  of  the  cyst,  and  if  it  be  an  adenoma,  the 
semi-solid  contents  are  freely  removed,  and  the  edges  of 
the  cyst  are  stitched  to  the  abdominal  wound  as  described 
in  the  preceding  section,  and  the  cavity  drained. 

This  mode  of  dealing  with  a  cyst  is  usually  termed 
"  incomplete  ovariotomy."  It  is  occasionally  referred  to  as 
"  marsupialization,"  because  the  cyst  forms  a  pouch  or  bag 
near  tlic  pubcs  resembling  that  of  the  kangaroo. 

An  incomplete  ovariotomy  is  a  very  different  condition 
to  an  enucleation.  T}>c  cavity  left  after  enucleation  closes 
completely,  but  when  the  wall  of  an  ovarian  C)'st  or 
adenoma  is  left,  the  tumor  gradually  reappears,  or  it  may 
suppurate  so  profusely  that  the  patient  slowly  dies  ex- 
hausted. There  arc  few  things  sadder  in  surger}'  than 
the  slow,  miserable  ending  of  an  indi\'idual  who  has  been 
subject  to  an  incom[)lctc  ovariotomy. 

Anomalous  Ovariotomy. — In  a  few  instances,  gener- 
ally under  an  erroneous  diagnosis,  surgeons  have  removed 
ovarian  tumors  through  an  incision  other  than  the  classical 
one  in  the  linea  alba.  Under  the  impression  that  the  tumor 
was  splenic  an  ovarian  tumor  of  the  right  side  has  been 
successfully  removed  through  an  incision  in  the  left  linea 
semilunaris. 


OVARIOTOMY  AND    OOPIIOR ECTOMY.  395 

An  ovarian  tumor  supposed  to  be  a  renal  cyst  has  been 
successfully  extracted  through  an  incision  in  the  ilio-costal 
space. 

Strangest  of  all,  a  small  ovarian  dermoid  has  been 
removed  through  the  rectum  under  the  impression  that 
it  was  a  polypus  of  the  bowel. 

Repeated  Ovariotomy. — Very  many  cases  are  known 
in  which  women  have  been  twice  submitted  to  ovariotomy. 
Thus  it  is  the  duty  of  the  surgeon  when  removing  an 
ovarian  tumor  to  examine  carefully  the  opposite  ovary.  So 
many  examples  are  known  of  women  who  have  borne 
children  after  unilateral  ovariotomy  (twins  and  even  triplets) 
that  this  alone  is  sufficient  to  prohibit  the  routine  ablation 
of  both  glands. 

A  second  ovariotomy  is  not  attended  with  more  risk 
than  the  first,  but  more  care  is  needed  in  making  the 
incision,  for,  should  a  piece  of  intestine  be  adherent  to  the 
cicatrix,  it  would  be  very  liable  to  injury. 

OOPHORECTOMY. 

This  signifies  the  removal  of  the  ovaries  and  Fallopian 
tubes  through  an  abdominal  incision,  for  affections  mainly 
inflammatory ;  also  the  removal  of  healthy  ovaries  and 
tubes  in  order  to  anticipate  the  menopause. 

This  operation  is  performed  for  the  relief  of  a  variety  of 
diseases  connected  with  the  internal  generative  organs: 

(I.)  Tubal  diseases,  such  as  pyosalpinx  and  tubo- 
ovarian  abscess ;  hydrosalpinx ;  tubercular  salpingitis ; 
tumors  of  the  tube — myoma,  adenoma,  carcinoma ;  gravid 
tubes  ;  ha^matosalpinx. 

(II.)  Ovarian  diseases;  for  example,  ovarian  abscess; 
apoplexy  of  the  ovary ;  hernia  of  the  ovary ;  prolapse  of 
the  ovary. 

(III.)  To  produce  artificial  amenorrhoea  in  such 
conditions  as  uterine  niyomata  ;  luL-matocolpos  or  heumato- 
metra ;  osteomalacia. 


396  DISEASES   OF   WOMEN. 

(IV.)  In  Nerve  Troubles. — Oophorectomy  has  been 
performed  in  order  to  anticipate  the  menopause  in  hystero- 
cpilcpsy  ;  epilepsy  ;  some  forms  of  insanity  ;  dysmcnorrhoea 
unassociatcd  with  demonstrable  diseases  in  the  ovaries. 

For  the  performance  of  oophorectomy  the  patient  is  pre- 
pared as  for  ovariotomy,  and  the  instruments  needed  are 
the  same  with  the  exception  of  the  trocar.  The  Trendelen- 
burg position  is  of  great  advantage,  as  it  enables  the  surgeon 
to  view  distinctly  the  depths  of  the  pelvis. 

The  abdomen  is  opened  in  the  usual  manner  and  situa- 
tion :  the  surgeon  then  seeks  the  fundus  of  the  uterus,  and 
with  this  as  a  guide  he  is  able  to  find  the  ovary  and  Fallo- 
pian tube.  When  the  parts  are  not  adherent  it  is  a  very 
simple  matter  to  seize  the  ovary  and  tube,  draw  them  into 
the  incision,  and  retain  them  in  position  by  pedicle-forceps, 
whilst  the  broad  ligament  is  transfixed  and  secured  with 
silk  ligatures.  When  the  tubes  are  filled  with  pus  and 
fixed  with  firm  adhesions  to  the  floor  of  the  pelvis,  and 
perhaps  intestine,  the  manipulations  necessary  to  detach 
the  tubes  and  ovaries  from  their  surroundings  demand 
great  care  and  the  exercise  of  much  patience. 

When  the  tubes  are  in  the  condition  of  pyosalpinx,  the 
tubal  tissues  are  in  places  so  thin  that  even  under  the  most 
cautious  fingers  the  sac  bursts  and  septic  fluid  rushes  into 
the  pelvis. 

On  the  other  hand,  the  ovaries  may  be  so  firmly  fixed 
to  the  floor  of  the  pelvis  that  they  break  and  portions  of 
ovarian  tissue  are  left ;  this  often  impairs  the  subsequent 
results,  as  menstruation  continues  if  only  a  portic^n  of  an 
ovary  is  left. 

In  the  case  of  oophorectomy  for  uterine  nn'onia  the  ova- 
ries in  many  cases  are  easily  found  :  occasionally  it  hai)pcns 
that  the  ovary  on  one  side  is  easily  reached  and  manipu- 
lated, but  the  other  is  so  incorporated  with  the  myoma  that 
it  cannot  be  entirely  removed  ;  hence  the  prudent  surgeon 
assures  himself  of  the  possibility  of  removing  both  sets 


OVARIOTOMY  AND    OdmORECTOMY.  397 

of  appendages  before  he  proceeds  to  apply  the  hga- 
ture. 

In  order  to  perform  oophorectomy  satisfactorily,  the  es- 
sential point  is  to  be  able  to  bring  the  ovaries  and  tubes 
into  the  wound  to  permit  the  application  of  the  ligatures ; 
these  are  applied  in  exactly  the  same  manner  as  in  ovari- 
otomy. The  assistant  must  be  especially  careful  to  avoid 
dragging  on  the  tubes  and  ovaries,  for  they  tear  easily,  and 
the  ligatures  need  to  be  very  cautiously  tied,  as  any  jerk- 
ing is  very  apt  to  lacerate  the  tissues  and  necessitate 
retransfixion. 

When  oophorectomy  is  practised  for  myoma  of  the  ute- 
rus, one  difficulty  is  to  obtain  sufficient  tissue  between  the 
ovary  and  the  uterus  to  make  a  secure  pedicle,  because  the 
mesometrium  is  so  stretched  that  when  the  parts  are  tied  and 
cut  away,  the  tension  upon  the  ligatures  is  so  great  that  they 
may  slip  off.  When  this  happens  in  the  course  of  the  ope- 
ration it  is  sometimes  very  difficult  to  discover  and  secure 
the  vessels,  and  in  very  many  cases  it  has  been  necessary  to 
perform  hysterectomy  to  control  the  bleeding.  Should  the 
accident  happen  after  the  patient  has  been  returned  to  bed, 
it  is  in  most  cases  fatal. 

After-treatment. — This  is  conducted  on  the  same  lines  as 
after  ovariotomy. 

The  dangers  are  the  same,  but  oophorectomy  is  attended 
with  greater  risk  to  life  than  ovariotomy.  It  is,  however, 
important  to  remember  that  the  greatest  operative  risk  is 
with  those  cases  in  which  the  necessity  for  surgical  inter- 
ference is  the  greatest. 

When  oophorectomy  is  performed  for  pyosalpinx,  there 
is  risk  with  the  pedicle,  because  its  tissues  are  often  infected, 
and  this  may  cause  it  to  slough  and  set  up  fatal  peritonitis 
or  give  rise  to  an  abscess  in  the  stump  which  may  burst 
through  the  scar,  the  rectum,  or  bladder. 

When  only  a  small  portion  of  an  ovary  is  left  behind 
menstruation  will  continue,  and  when  double  oophorectomy 


398  DISEASES   OF   WOMEN. 

is  pcrfoiiiicd  to  anticipate  the  menopause,  such  an  accident 
will  nullify  the  ^ood  expected  of  the  operation. 

When  oophorectomy  is  performed  for  my(jma  of  the  ute- 
rus the  ^reat  risk  is  hemorrhage. 

The  scquclie  arc  the  same  as  after  ovariotomy. 


CHAPTER    XLV. 
OVARIOTOMY  AND  OOPHORECTOMY  (Continued). 

THE    AFTER-TREATMENT   AND    RISKS. 

The  patient  is  returned  to  a  warm  bed  with  gentleness, 
to  avoid  vomiting :  a  pillow  is  placed  under  her  knees. 
Care  must  be  taken  that  the  hot-water  bottles  do  not  come 
in  contact  with  the  patient's  skin,  so  as  to  cause  blisters. 
As  consciousness  returns,  pain  is  complained  of,  and,  if  se- 
vere, it  may  be  relieved  by  morphia,  either  subcutaneously 
or  in  the  form  of  a  suppository.  The  routine  use  of  this 
drug  is  injudicious. 

Vomiting. — This  troublesome  complication  is  best  re- 
lieved by  keeping  the  stomach  empty  at  least  twenty-four 
hours.  If  there  is  faintness  or  shock,  stimulants,  such  as 
brandy  and  water,  or  even  milk,  beef-tea,  or  the  like,  may 
be  administered  by  the  rectum.  The  bowel  will  easily  re- 
tain three  ounces  of  beef-tea  at  a  temperature  of  ioo°  F.^ 
slowly  injected.  In  some  cases  the  vomiting  persists  for 
two  or  more  days,  and  when  accompanied  by  increased  fre- 
quency of  pulse  and  distention  of  the  belly,  it  is  usually  an 
unfavorable  sign. 

Diet. — At  the  end  of  twenty-four  hours  small  quantities 
of  barley-water,  water,  or  milk  and  soda-water  may  be  given 
by  the  mouth  at  regular  intervals  :  at  the  end  of  three  days 
the  bowels  should  be  relieved  by  an  enema,  and  then  boiled 
fish  or  fowl  may  be  allowed,  and  the  patient  soon  requires 
convalescent  diet. 

Distention  of  the  abdomen  is  due  to  the  accumula- 
tion of  gas  in  the  intestines.     It  is  usually  first  observed  in 

399 


400  DISEASES   OE   WOMEN. 

the  transverse  colon.  It  occasions  in  some  cases  nuich  dis- 
comfort, ami  it  is  not  always  easy  to  relieve  it.  The  j)as- 
sagc  of  the  rectal  tube  every  three  hours  as  a  matter  of 
routine  is  useful,  or  the  administration  of  a  small  enema. 

The  Bladder. — The  urine  requires  to  be  drawn  off  by 
the  nurse  every  eight  hours  by  means  of  a  clean,  soft  ca- 
theter. Before  passing  the  catheter  the  nurse  batlies  the 
orifice  of  the  urethra,  so  that  no  mucus  is  convej'cd  from 
the  vulva  into  the  bladder.  It  is  a  good  plan  to  encourage 
patients  to  pass  water  unaided. 

To  Clean  a  Catheter. — Immediately  after  use  the  catheter 
should  be  syringed  with  warm  water,  then  with  warm  sub- 
limate solution  (i  in  2000)  or  a  solution  of  carbolic  acid 
(i  in  20);  it  is  then  immersed  in  a  glass  tube  containing 
one  of  the  above-named  solutions.  Before  using  a  catheter 
it  should  be  wiped  with  a  piece  of  sterilized  gauze  and 
thoroughly  oiled. 

Bowels. — At  the  end  of  four  or  five  days  the  bowels 
will  occasionally  act  of  their  own  accord.  Usually,  how- 
ever, it  is  necessary  to  use  a  simple  enema ;  and  this  is,  in 
the  majority  of  cases,  quite  sufficient.  When  opium  has  been 
freely  administered,  still  more  active  measures  may  be  re- 
quired. 

Temperature. — This  should  be  observed  every  four  or 
six  hours  and  duly  recorded  in  the  note-book.  The  first 
record  after  the  operation  is  usually  subnormal ;  in  twelve 
hours  it  becomes  normal,  and  may  even  be  raised  half  a 
degree.  During  the  first  twenty-four  hours  it  may  ascend 
to  100°  F.  without  causing  alarm ;  beyond  this,  especially 
if  accompanied  by  a  rapid  pulse,  an  anxious  face,  and  dis- 
tended belly,  it  is  sufficient  to  make  the  surgeon  anxious. 
A  temperature  of  101°  or  102°  F.,  unaccompanied  by  other 
unfavorable  symptoms,  is  not  a  cause  for  alarm  unless  main- 
tained. The  very  high  temperatures  which  used  to  alarm 
surgeons  were  due  to  absorption  of  carbolic  acid,  especially 
when  the  spray  was  in  fashion. 


oiWKioroMY  AND  ()0j'noki:cio.\n:  401 

Pulse. —  This  is  a  valuable  !4uiclc,  and  even  more  trust- 
worthy than  the  temperature.  When  the  pulse  remains 
steady  and  full  there  is  no  cause  for  alarm.  When  it  in- 
creases in  frequency  to  120  or  130  or  more  beats  in  the 
minute  and  is  thin  and  thready,  then  there  is  danger  even 
with   the  temperature   only   slightly   raised. 

Metrostaxis. — After  operations  for  the  removal  of  both 
ovaries  and  tubes  blood  sometimes  escapes  from  the  uterus 
and  simulates  menstruation.  It  usually  begins  within  the 
first  forty-eight  hours  after  the  operation.  Metrostaxis 
occurs  in  or  about  one-half  the  cases,  and  has  nothing  to 
do  with  menstruation. 

Sutures. — On  the  seventh  or  eighth  day  the  sutures 
will  require  removal.  It  is  a  good  plan  to  allow  two  to 
remain  (taking  care  not  to  leave  any  that  are  causing  irrita- 
tion) twenty-four  hours  longer.  After  rerhoving  the  sutures 
a  broad  band  of  adhesive  plaster  should  be  firmly  fastened 
across  the  abdomen,  with  a  good  grip  on»each  hip.  This 
precaution  is  necessary,  as  an  incautious  or  violent  move- 
ment, such  as  coughing  or  straining,  may  cause  the  skin- 
edges  of  the  wound  to  gape. 

Should  suppuration  or  stitch-hole  abscesses  occur — and 
these  are  rare — they  must  be  treated  on  general  principles. 

Bed-sores  may  give  trouble  after  ovariotomy  in  an  el- 
derly and  enfeebled  patient,  as  after  any  other  surgical  pro- 
cedure which  requires  the  patient  to  remain  for  several  con- 
secutive days  upon  her  back.  With  due  care  and  watchful- 
ness on  the  part  of  the  nurse,  a  bed-sore  should  not  occur. 

THE  RISKS  OF  OVARIOTOMY. 

The  performance  of  ovariotomy  is  attended  by  several 
risks;  the  chief  are  indicated  in  the  subjoined  list:  (i) 
Shock;  (2)  Injur}-  to  viscera;  (3)  Bleeding;  (4)  Perito- 
nitis; (5)  Foreign  bodies  left  in  the  belly;  (6)  Tetanus; 
(7)  Parotitis  (septic);  (8)  Insanity;  (9)  Thrombosis  and 
embolism. 

26 


402  J)js/:asj:s  oi-  \vomea\ 

(i)  Shock. — This  varies  greatly.  The  removal  of  even 
a  small  ovarian  tumor  may  be  followed  by  ^reat  collapse. 
It  is  more  common  after  prolonged  operations  and  enuclea- 
tion of  tumors  from  the  mesometrium. 

Generally  the  patient  quickly  reacts  on  her  return  to  bed. 
After  severe  operations  the  patient  may  not  re^c^ain  con- 
sciousness for  some  hours,  and  occasionally  collapse  ter- 
minates in  death. 

(2)  Injury  to  Viscera. — Those  most  liable  to  injury 
durini;  ovariotom}-  are — [ii)  The  intestines  ;  (/->)  The  blad- 
der ;  (r)  the  ureters ;   i^ii)  the  gravid   uterus. 

{(i)  Intestines. — These  may  be  cut  or  lacerated  in  making 
the  abdominal  incision  ;  more  frequently  they  are  torn  in 
detaching  adhesions.  The  vermiform  appendix  has  been 
divided  before  its  nature  was  suspected.  The  bowel  has 
been  pierced  by  the  pedicle-needle  whilst  passing  the  liga- 
tures, and  has  even  been  tied  to  the  i)edicle.  In  suturing 
the  abdominal  wall  the  intestines  have  not  only  been  pricked, 
but  accidentally  stitched  to  the  belly-wall. 

Wounds  of  intestine  should  be  immediateh'  sutureil  with 
fine  silk.  A  wound  of  intestine  overlooked  is  almost  cer- 
tainly fatal. 

(/;)  Tlic  Bladder. — A  full  bladder  has  been  punctured 
with  a  trocar  in  mistake  for  a  c)'st :  it  has  been  opened  in 
making  the  abdominal  incision  and  torn  in  separating  adhe- 
sions. Wounds  of  the  bladder  should  be  immediately 
closed  with  fine  silk  sutures. 

(r)  The  Ureter. — This  duct  has  been  torn  in  sei^irating  ad- 
hesions on  the  floor  of  the  j)elvis  and  at  the  brim  of  the 
pelvis.  It  is  especially  liable  to  damage  during  the  process 
of  enucleating  tumors  from  the  mesometrium. 

Small  wounds  may  be  closed  with  a  suture.  When 
the  duct  is  completely  divided,  the  upj^er  end  should,  if 
possible,  be  invaginated  into  the  lower ;  failing  this,  the 
proximal  end  is  brought  out  of  the  wound.  This  will 
entail  a   subsequent    ncphrcctonu-.     A    ureter  accidentally 


OVARIOTOMY  AND    OdrHORKCTOMY.  403 

divitlcd  luis  been  successfully  en^rafteti  into  the  wall  of  the 
bladder. 

{d)  Injury  to  a  Gravid  Uterus. — When  ovariotomy  is 
undertaken  during  pregnancy  the  surgeon  is  necessarily 
on  his  guard  against  mistaking  the  enlarged  uterus  for  a 
cyst.  Injury  is  very  liable  to  happen  when  there  has  been 
an  error  of  diagnosis  and  pregnancy  mistaken  for  a  cyst. 

To  plunge  a  trocar  into  a  gravid  uterus  is  a  serious  mis- 
fortune, and  has  happened  on  several  occasions.  In  such 
conditions  there  are  three  courses  open  to  the  surgeon:  (i) 
Perform  a  Czesarean  section ;  (2)  Amputate  the  uterus ; 
(3)  Sew  up  the  puncture  without  disturbing  the  uterine 
contents. 

Each  of  these  methods  has  been  practised  with  success, 
but  Cesarean  section  has  so  far  given  the  best  results. 

(3)  Bleeding. — Intermediate  hemorrhage  may  be  due  to 
the  slipping  of  an  ill-applied  ligature  from  the  pedicle  or  an 
adhesion. 

Oozing,  which  is  scarcely  appreciable  when  a  patient  is 
collapsed,  may  become  very  free  when  reaction  occurs. 

Severe  internal  bleeding  is  manifested  by  well-known 
signs — pallor,  cold  skin,  rapid  but  feeble  pulse,  and  sighing 
respiration.  When  these  signs  are  manifested,  the  wound 
must  be  reopened,  the  clots  turned  out,  and  the  bleeding 
point  secured. 

Hemorrhage  usually  occurs  within  the  first  thirty-six 
hours.  After  enucleation  has  been  practised  and  the  broad 
ligament  ligatured,  but  not  drained,  bleeding  may  take  place 
within  it  and  form  a  hajmatoma.  As  a  rule,  it  is  slowly 
absorbed. 

(4)  Peritonitis. — This  wms  formerly  the  terror  of  the 
ovariotomist.  Its  frequency  has  been  diminished  by  im- 
proved methods  of  dealing  with  the  pedicle,  greater  cleanli- 
ness, antiseptic  and  aseptic  precautions,  and  the  employment 
of  irrigation  with  or  without  drainage.  Peritonitis  may 
arise  from  infection  at  the  time  of  the  operation  in  consc- 


404  J)/sj-:.isj:s  oj-   U(>a//:a'. 

quciicc  of  the  escape  of  pus  or  utlier  lluids  from  llie  interior 
t)f  cysts  or  tumors ;  from  sponj^es  and  instruments  inadver- 
tently left  in  the  abdomen  ;  from  operations  conducteil  in 
rooms  in  which  sewer-j^as  and  similar  deleterious  a^'ents  are 
present ;  from  damage  to  and  subsequent  sloughing  of  por- 
tions of  the  viscera,  gangrene  of  the  stump,  pieces  of  adhe- 
rent cyst-wall,  or  adhesions;  from  decomposition  of  blood 
carelessly  left  in  the  pelvis  or  that  has  oozed  after  the 
operation. 

Its  occurrence  in  a  fatal  form  is  not  likely  to  be  mistaken. 
The  pulse  is  rapid  (120,  130,  or  140),  at  finst  full  and  bound- 
ing, then  quickly  becoming  thin  and  feeble.  The  tempera- 
ture may  be  subnormal,  then  slowly  rise  to  100°,  102"^,  or 
103°  F.  These  signs,  accompanied  by  vomiting,  the  fluid 
being  bile-stained  or  like  black  coffee,  an  anxious  and 
pinched  face,  sunken  eyes,  and  distended  abdomen,  form  a 
picture  never  mistaken  when  once  seen.  Death  is  rarely 
long  dcl:i\'cd. 

(5)  Foreign  Bodies  I^eft  in  the  Abdomen. — Iwery 
writer  on  ovariotomy  insists  on  the  importance  of  exercis- 
ing the  utmost  personal  vigilance  in  counting  instruments, 
and  especially  sponges,  after  an  abdominal  oj)eration. 
Nearly  all  the  cases  in  which  foreign  bodies  are  left  in  the 
abdomen  end  fatally,  and  more  than  one  writer  has  ex- 
pressed the  opinion  that  the  accident  has  probably  been 
overlooked  where  no  post-mortem  examination  was  made. 

Besides  sponges  and  forceps,  such  things  as  pads  of  tar- 
letan,  iodoform  rauze,  and  a  drainage-tube  have  been  left 
in   the  ccelom. 

In  a  few  lucky  cases  a  sponge  or  compres.s  has  given  rise 
to  an  abscess,  and  the  foreign  body  has  been  discharged, 
.sometimes  through  the  belly-wall,  sometimes  through  the 
anus.  Forceps  thus  left  behind  have  made  their  way  into 
the  bladder,  the  caecum,  or  have  escaped  at  the  navel  many 
months  after  the  operation. 

(6)  Tetanus. — Since  the  clamp  has  been   jjanished,  tet- 


Or.tA'/O'JOA/V  AiXD    OOPJJORKC'JOMY  405 

aims  rarely  attacks  the  abdominal  wound.  Ovariotomy 
should  iu)t  be  performed  in  rooms  recently  plasteretl.  In 
practice  it  is  to  be  remembered  that  tetanus  arises  from 
infection,  and  all  instruments  which  have  been  in  contact 
with  a  case  of  tetanus  should  be  sterilized  by  prolonged 
boilinc:^. 

(7)  Parotitis. — Inflammation  of  the  parotid  gland  is  apt 
to  complicate  injuries  to,  and  operations  upon  and  in,  the 
abdomen.  One  or  both  glands  may  be  affected,  and  in  a 
large  proportion  of  cases  suppuration  occurs.  This  form 
of  parotitis  runs  no  regular  course :  it  may  subside  and 
recur  in  the  course  of  the  convalescence  from  the  original 
injury  or  operation. 

(8)  Insanity. — Acute  mania  occasionally  complicates 
the  convalescence  from  ovariotomy.  It  was  common  dur- 
ing "the  reign  of  the  carbolic  spray."  In  the  majority  of 
cases  it  quickly  subsides. 

(9)  Vascular  Disturbances. — Thrombosis  of  the  iliac 
veins  sometimes  follows  ovariotomy,  and  gives  rise  to 
oedema,  usually  of  one  leg. 

Embolism  of  the  pulmonary  artery  has  been  several 
times  recorded  in  the  course  of  convalescence  from  ova- 
riotomy, but  the  diagnosis  has  only  been  demonstrated  by 
actual  dissection  in  very  few  instances. 

The  Sequelae  or  Remote  Risks  of  Ovariotomy. — 
These  include — (i)  Intestinal  obstruction;  (2)  Perforation 
of  the  intestine ;  (3)  Trouble  with  the  ligature  ;  (4)  Yielding 
cicatrix. 

(i)  Intestinal  Complications. — It  is  difficult  to  esti- 
mate with  any  approach  to  accuracy  the  relative  frctiucncy 
of  intestinal  complications  following  ovariotomy.  The  dan- 
ger is  nevertheless  real. 

Intestinal  obstruction  may  be  acute  or  chronic — may  su- 
pervene within  a  few  days  of  the  operation  or  be  delayed 
for  months  or  years.  The  causes  are  fourfold  :  {li)  The 
formation  of  a  band;  (/-')  adhesions  to  the  pedicle;   (r)  ad- 


4o6  .        J)/s/-:asI':s  oi-  womj.n. 

licsions  to  the  cicatrix  ;  {d)  strangulation  in  a  sac  formed  by 
a  )'ielclin_t^  cicatrix. 

(2)  Perforation  of  Intestine. —  This  may  arise  from 
pressure  of  a  drain-tulie  or  daniaj^fe  to  the  wall  of  the  gut 
in  separating  adhesions.  The  rectum  is  tiie  most  frequent 
seat  of  this  accident. 

(3)  The  I<igature. — When  a  piece  of  silk  thread  or 
whipcord  thoroughly  sterilized  by  boiling  is  applied  to  a 
healthy  pedicle,  if  causes  no  evil  consequences,  and  is  cither 
encysted  or  slowly  removed  by  the  aggressive  leucocytes. 
The  thread  disappears  in  about  a  year,  but, the  knots  re- 
quire at  least  an  additional  six  months. 

When  the  tissues  of  the  pedicle  are  infiltrated  with  in- 
flammatory products,  especially  when  the  Fallopian  tube  is 
septic,  the  ligature,  instead  of  being  absorbed,  excites  in- 
flammation and  becomes  surrounded  with  pus.  An  abscess 
around  the  pedicle  may  give  rise  to  the  following  compli- 
cations :  (^  fatal  peritonitis ;  {b)  the  abscess  may  open 
through  the  abdominal  cicatrix  and  form  a  sinus ;  (r)  it 
may  perforate  the  rectum  or  even  the  bladder. 

When  a  sinus  results  from  an  abscess  of  the  pedicle  it 
usually  persists  until,  the  ligature  is  discharged  :  this  may 
require  many  months.  When  the  ligature  escapes  into  the 
bladder,  it  may  form  the  nucleus  of  a  vesical  calculus. 

(4)  The  Cicatrix. — One  of  the  most  troublesome  and 
frequent  sequeLx  of  ovariotomy  used  to  be  a  yielding  cica- 
trix, which  allowed  the  formation  of  a  large  ventral  hernia. 
In  very  many  cases  these  hernial  caused  more  trouble  than 
the  disease  for  which  the  operation  was  performed,  besides 
being  a  source  of  danger. 

The  inconvenience  of  wearing  a  belt  is  such  that  many 
women  prefer  to  run  the  risk  of  hernia  rather  than  be  en- 
cumbered with  such  an   apparatus. 

When  the  abdominal  incision  is  closed  with  a  triple  series 
of  sutures,  as  described  on  page  383,  the  chance  of  a  yield- 
ing cicatrix  is  very  slight  and  the  belt  ma\'  lie  discarded. 


OVARIOTOMY  AND    OOPHORECTOMY.  407 

Cancer  of  the  Cicatrix. — Cases  have  been  reported  in 
which,  after  removal  of  ovarian  adenomata,  tumors  similar 
in  structure  have  appeared  in  the  scar.  In  some  cases  such 
tumors  have  been  associated  with  wide  dissemination  due  to 
recurrence  of  a  malignant  tumor.  In  some  cases  the  tumor 
has  been  attributed  to  direct  infection  during  removal  of  the 
primary  tumor. 

The  Remote  Effects  of  Ovariotomy  on  the  Pri- 
mary and  Secondary  Sexual  Characters. — The  remov- 
al of  one  ovary  has  no  effect  upon  women,  and  a  large  num- 
ber of  instances  have  been  reported  in  which  pregnancy  has 
followed  unilateral  ovariotomy. 

The  removal  of  both  ovaries  is  followed  in  adult  women 
by  sterility  and  persistent  ameaorrhoea,  and  these  are  the 
only  two  constant  effects  which  can  be  attributed  to  it. 

The  amenorrhoea  is  practically  an  artificial  menopause, 
and  is  usually  accompanied  by  that  peculiar  vaso-motor 
phenomenon  characteristic  of  the  "  change  of  life,"  familiar 
to  climacterics  as  "  flushes."  The  influence  of  double  ova- 
riotomy on  the  sexual  passion  is  hard  to  estimate,  and  can- 
not be  taken  into  account  when  the  life  of  the  individual  is 
directly  concerned.  Women  have  lived  happily  with  their 
husbands  after  removal  of  both  ovaries.  The  nubility  of 
women  after  double  ovariotomy  is  a  difficult  question.  It  is 
certain  that  many  women  have  married  after  removal  of 
both  ovaries. 

There  is  no  evidence  that  complete  removal  of  both 
ovaries  in  a  mature  woman  leads  to  any  unusual  develop- 
ment of  the  secondary  sexual  characters,  or  atrophy  of  the 
breasts.  It  may  cause  obesity  in  a  woman  who  has  a  tend- 
ency to  form  fat. 


CHAPTER    XLVI. 
OPERATIONS   FOR  TUBAL  PREGNANCY. 

For  the  performance  of  these  operations  the  methods  arc 
very  similar  to  those  for  oophorectomy  and  the  enucleation 
of  cysts  from  the  mesometrium.  We  shall  therefore  merely 
mention  the  special  details. 

At  the  Time  of  Primary  Rupture. — In  this  stage  the 
surgeon  opens  the  abdomen  in  the  middle  line,  and  on 
dividing  the  peritoneum  there  is  usually  a  free  rush  of  liquid 
blood.  The  hand  is  immediately  introduced  into  the  belly, 
and  on  recognizing  the  fundus  of  the  uterus  the  surgeon 
passes  his  hand  along  the  Fallopian  tube,  first  on  one  side, 
then  on  the  other,  to  distinguish  that  which  is  damaged. 
The  tube  is  then  drawn  into  the  incision  and  clamped  with 
forceps ;  the  mesometrium  is  then  transfixed,  and  the  liga- 
tures secured  exactly  as  described  under  the  operation  of 
oophorectomy. 

The  free  blood  and  clot  arc  then  removed,  and  if  the 
surroundings  are  favorable  for  the  purpose,  the  pelvis  is 
freely  irrigated.  Otherwise  the  blood  and  clot  are  thor- 
oughly removed  by  cautious  sponging.  Care  is  taken  to 
remove  blood  which  may  have  lodged  in  the  iliac,  the  utcro- 
vesical,  or  the  recto-vaginal  fossa.-. 

When  the  blood  is  thoroughly  removed  either  by  irriga- 
tion or  sponging  there  is  no  need  for  drainage. 

The  wound  is  then  sutured  and  dressed  as  after  ovari- 
otomy. 

Aftcr-trcatiiioit. — This  is  of  verj'  great  importance,  for 
the  great  loss  of  blood  and  the  shock  place  these  jiatients  in 
a  very  critical  condition.     As  soon  as  the  j)atient  is  returned 

4(18 


OPERATIONS  FOR    TUBAL    PR  EG  NANCY.  409 

to  bed,  warm  bottles  are  placed  around  her,  and  an  enema 
consisting  of  three  ounces  of  milk  (or  beef-tea  or  even  warm 
water)  and  half  an  ounce  of  brandy  is  injected  into  the  rec- 
tum every  hour  for  twelve  hours.  Its  continuance  is  then 
determined  by  the  state  of  the  pulse.  To  relieve  thirst,  for 
a  few  hours  the  patient  is  allowed  to  wash  the  mouth  with 
cold  water  or  even  to  sip  hot  water. 

At  the  end  of  twenty-four  hours  there  is  generally  pain  in 
the  belly  (due  to  attempts  to  expel  the  decidua).  To  relieve 
this,  twenty  drops  of  laudanum  niay  be  added  to  the  enema. 
The  nutrient  enemata  may  be  discontinued  at  the  end  of 
twenty-four  or  thirty-six  hours,  and  the  patient  fed  freely 
by  the  mouth  if  there  be  no  vomiting. 

Subsequent  to  Primary  Rupture. — When  it  is  neces- 
sary to  interfere  with  a  collection  of  blood  in  the  recto- 
vaginal fossa,  the  belly  is  opened  in  the  middle  line,  and  on 
reaching  the  clot  the  surgeon  removes  it  with  his  fingers, 
and  then  attempts  to  bring  the  damaged  tube  into  the  wound, 
and  removes  it  as  in  oophorectomy.  The  blood-containing 
recess  is  freely  irrigated  or  thoroughly  sponged. 

In  cases  where  the  blood  has  been  standing  for  several 
weeks  it  is  usually  advisable  to  employ  drainage. 

After-treatment. — This  is  conducted  on  the  same  lines  as 
after  enucleation  of  sessile  cysts. 

Mesometric  Rupture  {HiEinatoma). — In  these  cases, 
unless  the  surgeon  has  had  considerable  experience  in  this 
class  of  surgery,  he  is  liable  to  be  extremely  puzzled  to 
make  out  the  nature  of  the  swelling  when  he  has  incised 
the  parietes.  The  bulging,  dark-red  mass  often  resembles 
a  solid  tumor.  To  attempt  its  enucleation  is  disastrous. 
All  that  is  required  is  a  free  incision  into  the  summit  of  the 
mass,  and  removal  of  the  embryo,  clot,  and  placenta.  The 
edges  of  the  sac-wall  are  stitched  to  the  skin-incision  and 
its  cavity  drained.  The  remainder  of  the  wound  is  closed 
as  after  ox^ariotomy. 

After  the  Fifth  Month. — The  operatixe  treatment  of 


410  DISEASES   Of-    WOMEN. 

the  late  stages  of  tubal  j)re<^nancy  has  already  been  con- 
sidered in  Chapter  XXVII.  The  method  of  performing  the 
operation  consists  in  making  a  free  incision  into  the  abdo- 
men, as  recommended  in  describing  cteliotomy.  The 
operator  then  endeavors  to  make  out  the  nature  of  the 
swelling  and  determines  its  relation  to  the  uterus.  He 
must  satisfy  himself  that  the  swelling  is  not  a  uterine  or  an 
ovarian  tumor.  When  he  feels  assured  that  he  is  dealing 
with  a  gestation  sac,  he  freely  incises  it  and  withdraws  the 
ftetus  with  its  placenta  and  the  surrounding  clot.  When 
the  fcetus  is  dead,  there  is  rarely  much  difficulty  with  the 
bleeding,  but  with  a  living  placenta  the  hemorrhage  at  this 
stage  is  often  appalling. 

The  necessity  for  correct  diagnosis  and  ready  appreci- 
ation of  the  pelvic  condition  is  very  great.  When  the  sur- 
geon mistakes  a  gestation  sac  for  a  tumor  and  attempts  to 
enucleate  it,  he  is  very  apt  to  injure  large  blood-vessels  or 
a  ureter,  or  tear  a  hole  in  the  bowel ;  whereas  when  the 
nature  of  the  case  is  recognized  and  the  sac  opened,  the 
walls  of  the  sac  isolate  the  field  of  operation  from  the  belly- 
cavity  and  prevent  injury  to  intestines  (except  the  rectum 
when  the  fcetus  occupies  the  left  mesometrium).  The  sub- 
sequent treatment  of  'the  case  is  the  same  as  that  advised 
after  enucleation  of  cysts  from  the  mesometrium. 

The  Risks  of  Coeliotomy  for  Tubal  Pregnancy  in 
its  I/ate  Stages. — When  the  foetus  is  dead  the  operative 
risks  are  very  small  indeed,  and  do  not  exceed  those  of 
ovariotomy. 

In  cases  where  the  foetus  is  alive  and  the  placental  circu- 
lation in  full  vigor  the  risks  are  greater  than  those  of  any 
other  abdominal  operation.  About  two-thirds  of  the 
patients  die.  The  risks  are  threefc^ld :  (i)  hemorrhage; 
(2)  shock  ;  (3)  peritonitis. 

The  risk  of  peritonitis  is  due  to  the  decomposition  of  the 
placenta  when  it  has  been  left  behind. 


CHAPTER    XL  VI  I. 

OPERATIONS   ON   THE    UTERUS. 

These  are — i  Hysterectomy;  2  Abdominal  Myomec- 
tomy; 3.  Caf.sarean  Section  ;  4.  Hysteropexy;  5.  Shorten- 
ini;  the  Round  Lis^aments. 

I.  Hysterectomy. — This  signifies  the  removal  of  the 
uterus,  and,  as  a  rule,  the  ovaries  and  the  Fallopian  tubes. 
When  the  uterus  is  removed  through  an  incision  in  the 
belly  the  operation  is  described  as  abdominal  hysterectomy. 

(a)  Supra-vag^inal  Hysterectomy. — The  preliminary 
stages  and  the  instruments  required  are  the  same  as  those 
for  an  ovariotomy. 

Steps  of  the  Operation. — In  this  method,  when  the  tumor 
scarcely  rises  out  of  the  pelvis,  it  is  a  great  advantage  to 
have  the  patient  in  Trendelenburg's  position. 

The  abdomen  is  opened  as  for  ovariotomy,  but  the  in- 
cision will  be  much  longer  to  enable  the  tumor  to  be  with- 
drawn. Its  actual  length  is  of  course  regulated  by  the  size 
of  the  tumor.  It  some  cases  it  will  extend  from  the  pubes 
to  a  point  near  the  ensiform  cartilage.  The  enlarged  uterus 
is  then  brought  out  and  the  intestines  protected  by  a  warm 
fiat  sponge.  The  surgeon  then  seeks  the  appendages,  and 
transfixes  the  broad  ligament  with  a  pedicle-needle  armed 
with  a  stout  silk  thread.  The  threads  are  tied  tightly,  and 
in  such  a  way  as  to  enable  the  tissues  between  the  two  liga- 
tures to  be  divided.  When  the  same  process  has  been  car- 
ried out  on  the  opposite  side  the  uterus  is  then  well  raised 
out  of  the  pelvis  by  the  assistant. 

The  surgeon   now   makes   a  transverse  cut  througli  the 

411 


412 


DISEASES   OE   WOMEN. 


peritoneum  on  tlic  anterior  surface  of  the  tumor  or  the  ute- 
rus, a  short  distance  above  the  level  of  the  bladder ;  then 
by  means  of  the  handle  of  the  scalpel  he  opens  up  the  con- 
nective tissue  between  the  bladder  and  the  uterus,  and  is 


Fig.  113. — A  utt-rinc  myoma  cxtnulcd  through  an  incision  in  ihc  linca  alba.     The  perito- 
neum is  reflected  to  show  the  uterine  arteries  (A    K.  G.). 


thus   able   to   peel   the   peritoneum   and   bladder   from  the 
uterus. 

A  similar  transverse  incision  is  made  across  the  posterior 
surface  of  the  tumor,  and  the  peritoneum  on  that  aspect  is 
carefully  })eeled  off  When  this  manoeuvre  is  propcrl)'  car- 
ried out  the  layers  of  the  broad  liijaments  arc  directly  con- 


OJ'ERATJONS    ON   TlIE    UTERUS. 


4'3 


tinuous  with  each   other,  the  cervix  of  the  uterus  staiidin!^ 
up  freely  between  them. 

The  operator  now  proceeds  to  hj;ature  the  uterine  artery 
on  each  side.  He  selects  a  stout  aneurysm-needle  set  at  a 
right  angle,  armed  with  a  stout  silk  ligature,  and  passes  it 
around  the  vessel  at  the  spot  where  it  passes  on  to  the  cervix 
(Figs.  1 1 3  and  1 14),  and  ties  it  securely.  Having  ligatured  the 
vessel  on  both  sides,  he  then  cuts  the  uterus  at  the  level  to 


Fig.  114.— a  stage  in  abdominal  hysterectomy,  showing  a  method  of  securing  the  uterme 
arteries  (Howard  Kcliy). 


which  he  has  reflected  the  peritoneum.  Sometimes  a  small 
vessel  may  bleed  in  the  stump  and  needs  to  be  secured. 
Often  the  uterine  arteries  are  clearly  seen,  and  they  may 
then  be  deliberately  tied  as  in  an  amputation  stump. 

The  floor  of  the  pelvis  and  the  parts  exposed  between  the 
split  broad  ligaments  are  carefully  sponged  and  freed  from 
blood  and  clots,  and  the  peritoneal  flaps  are  now  carefully 
sutured  together,  so  as  to  exclude  the  stump  from  the  pel- 
vic cavity.  The  abdominal  wound  is  then  sutured  in  the 
usual  manner. 


414  J)/sj:,is/:S  uJ'  no  men. 

Aftcr-trcatiiuiit. —  This  is  concliictLcl  on  the  same  lines  as 
after  ovariotomy,  and,  as  a  rule,  the  conv.ilescence  is  as 
(juick. 

The  special  risks  in  this  operation  are  hemorrhagic;  injury 
to  one  or  both  ureters  or  the  bladder ;  and  infection  of  the 
peritoneum  throui^^h  the  cervical  canal. 

(J))  Pan-hysterectomy. — This  signifies  the  removal  of 
the  whole  uterus  through  an  abdominal  incision,  and  differs 
from  the  preceding  method  in  that  it  leaves  no  stump. 

The  patient  is  prepared  as  for  ovariotomy,  but  in  addition 
the  vagina  is  carefully  made  aseptic,  and  it  sometimes  facili- 
tates matters  if  the  vagina  is  filled  with  aseptic  gauze. 

Trendelenburg's  position  assists  the  surgeon  greatly  in 
this  operation. 

The  early  stages  are  the  same  as  for  the  preceding 
method,  and  the  broad  ligaments  are  secured  with  silk 
ligatures.  The  bladder  is  stripped  from  the  uterus,  and  the 
surgeon  makes  his  way  downward  along  the  anterior  aspect 
of  the  cervix  into  the  vagina. 

The  posterior  connections  of  the  vagina  and  cervix  are 
severed  with  scissors,  and  at  the  lateral  angles  the  uterine 
arteries  may  be  secured  with  ligatures  before  division,  or 
they  may  be  caught  \Vith  forceps  and  divided,  the  cut  end 
being  securely  ligatured  with  silk.  TJie  cervix  is  then  de- 
tached from  the  lateral  aspect  of  the  vagina  and  removed. 
Any  spouting  vessel  in  the  mesometric  tissue  or  the  cut 
edges  of  the  vagina  is  secured  with  forceps,  and  the  margins 
of  the  divided  peritoneum  and  broad  ligaments  are  brought 
into  position  with  sutures,  thus  occluding  the  abdominal 
end  of  the  vagina. 

This  operation  is  sometimes  modified  in  the  following 
manner :  Before  opening  the  abdomen  the  patient  is  placed 
in  the  lithotomy  position,  and  the  cei-vix  freed  from  the 
bladder  and  vagina  as  in  the  first  stages  of  vaginal  hyste- 
rectoni)' :  then  the  patient  is  placed  in  the  Trendelenburg 
position  and  the  operation  completed  through  the  abdomen. 


OPK RATIONS   ON   'JJIK    UTERUS.  415 

After  the  suture  nf  the  broad  ligaments  the  pelvis  is  freed 
from  blood  and  clot  and  the  abdominal  wound  secured  as 
in  coeliotomy. 

It  sometimes  happens  in  the  performance  of  supra-vaginal 
hysterectomy  that  the  operator  is  able  to  peel  the  perito- 
neum off  the  cervix  below  the  level  of  the  insertion  of  the 
cervix  into  the  vagina.  When  this  is  the  case  and  the  uterus 
is  cut  away,  he  finds  that  he  has  opened  the  vagina  and  thus 
unwittingly  performed  a  pan-hysterectomy. 

Supra-vaginal  hysterectomy  and  pan-hysterectomy  may 
be  performed  easily,  safely,  and  quickly ;  convalescence  is 
as  rapid  and  as  uneventful  as  after  ovariotomy.  There  are 
many  modifications  described  by  various  surgeons,  but  the 
principles  are  those  related  above,  and  the  operation,  which 
gives  remarkable  results,  is  being  rapidly  perfected. 

2.  Myomectomy. — This  signifies  the  removal  of  a  pe- 
dunculated uterine  myoma  through  an  abdominal  incision, 
without  removal  of  the  uterus. 

The  patient  is  prepared  as  for  ovariotomy  or  hysterec- 
tomy, and  on  opening  the  abdomen  the  surgeon  finds  a 
myoma  growing  from  the  fundus  of  the  uterus  and  possess- 
ing a  narrow  pedicle  or  stalk  which  enables  the  tumor  to  be 
protruded  through  the  wound.  In  such  a  case  the  tumor 
may  be  removed  and  the  uterus  preserved. 

When  the  tumor  is  small  and  the  pedicle  narrow,  the 
latter  may  be  transfixed  and  ligatured  as  in  the  case  of  an 
ovarian  cyst :  the  tissue  of  the  pedicle  is  very  tough  and 
requires  to  be  tightly  tied. 

Enucleation  of  Myoniata. — Occasionally  a  myoma  of  large 
size  may  project  from  the  uterus  or  even  rest  incarcerated  in 
the  pelvis,  and,  though  projecting  from  the  uterus,  yet  offer 
so  short  a  pedicle  that  it  would  be  foil)'  to  attempt  to  se- 
cure it  with  ligatures.  In  such  a  case  there  is  an  alternative 
method.  The  tumor  should  be  well  exposed  and  its  capsule 
split  with  a  sharp  scalpel,  and  the  m)'oma  may  with  a  little 
care  be  rapidly  enuclcalcd  from  its  bed.     The  capsule  can 


4l6  /)/.SA.I.S/:S    OF   WOMEN. 

llicn  be  Ininchccl  tot^cthcr,  and  may  be  ulilizcd  as  a  pedicle, 
transfixed,  and  secured  witli  silk  ligatures  :  the  abdominal 
wound  can   then   be  completely  closed  as  in  ovariotomy. 

The  after-results  of  abdominal  myomectomy  and  enuclea- 
tion of  uterine  m)'t>ma  are  admirable,  as  the  surj^eon  is  able 
to  leave  not  merely  the  uterus,  but  the  ovaries  and  the  tubes 
as  well.  In  some  instances  the  patients  have  become  preg- 
nant aiul  hat!  happy  deliveries. 

Operations  on  the  Pregnant  Uterus. — The  opera- 
tions which  come  strictly  under  this  heading  are — 
Caesarean  Section ; 
Porro's  Operation  ; 

(3)  Caesarean  ^^Q.\.\.ovi  signifies  tJic  removal  of  a  fcvtus 
and  placenta  from  the  uterus  t/wougJi  an  incision  involving 
the  alxlominal  and  uterine  trails. 

When  it  is  known  some  days  beforehand  that  the  patient 
will  be  submitted  to  this  0[)eration,  she  should  be  prepared 
as  for  ovariotomy,  the  vulva  and  the  vagina  being  thor- 
oughly washed  and  douched.  Often  it  happens  that  the 
operation  is  undertaken  after  laljor  has  commenced  and  in 
circumstances  which  make  time  very  precious.  Even  then 
the  abdomen,  pubes,  and  vulva  can  be  thoroughly  washed 
with  warm  soap  and  water  and  lightly  rubbed  with  chloro- 
form and  cotton-wool. 

Instrunioits. — A  scalpel ;  probe-pointed  knife  ;  volsella ; 
six  pressure-forceps;  scissors;  suture-needles,  curved  and 
straight;  catheter;  sterilized  ligature  silk,  catgut,  and  silk- 
worm  gut. 

The  Abdominal  Incisioti. — After  the  patient  is  under  the 
influence  of  ether  and  the  bladder  emptied  with  the  catheter, 
an  incision  is  made  in  the  linea  alba  from  the  umbilicus  to 
the  pubes.  The  belly-wall  of  a  woman  advanced  in  preg- 
nancy is  very  thin,  and,  unless  the  surgeon  be  cautious,  the 
knife  will  come  in  C(Mitact  with  the  uterus  before  he  is  aware 
of  it. 

The   uterus   lies  just   under  the  incision,  and  the  opera- 


OPERATIONS   ON  THE    UTERUS.  417 

\.ox  ascertains  that  it  lies  centrally  (often  the  uterus  is 
somewhat  rotated  to  the  rii^ht  or  left),  and  then  makes 
a  free  incision  through  the  uterine  wall  and  extracts  the 
fcutus  and  placenta:  as  the  uterus  contracts  he  slips  his  left 
hand  behind  the  fundus  and  grasps  the  uterus  near  the 
cervix,  and  effectually  controls  the  bleeding.  The  assist- 
ant passes  a  large  warm  fiat  sponge  into  the  belly  to  restrain 
the  intestines  and  omentum.  Should  the  surgeon  be  anx- 
ious about  the  bleeding,  he  may  apply  a  whipcord  ligature 
around  the  uterus.  The  uterine  cavity  is  sponged  out,  and 
the  finger  passed  along  the  cervical  canal  into  the  vagina 
in  order  to  ensure  a  free  passage  for  blood  and  serum. 

We  now  come  to  the  most  important  stage  of  the  opera- 
tion— namely,  suture  of  the  uterine  incision.  The  wall  of 
the  uterus  has  an  inner  layer  of  mucous  membrane,  then 
a  thick  stratum  of  muscle-tissue,  and  finally  an  outer  layer 
of  peritoneum.  The  wound  is  first  closed  wnth  a  series  of 
sterilized  silk  sutures  which  involve  the  mucous  and  adja- 
cent half  or  thereabouts  of  the  muscular  layer.  These 
sutures  should  be  fairly  close  together,  for  they  not  only 
bring  the  parts  into  apposition,  but  serve  to  restrain  the 
bleeding.  A  second  row  of  silk  sutures  is  now  inserted, 
including  the  serous  coat  and  adjacent  half  of  the  mus- 
cular layer.  These  threads  should  not  be  tied  too  tightly, 
as  the  tissues  of  a  gravid  uterus  are  soft  and  easily  tear. 
In  closing  the  uterine  incision  the  surgeon  should  not 
spend  time  in  vainly  endeavoring  to  staunch  the  bleed- 
ing from  the  edges  of  the  incision  :  this  is  best  effected  by 
dextrously  inserting  and  securing  the  sutures. 

The  recesses  of  the  pelvis  are  carefully  cleaned  by  gentle 
sponging,  and  the  parietal  wound  closed  as  after  ovariotomy. 
The  dressing  varies  according  to  the  fancy  of  the  operator : 
whatever  its  nature,  it  is  secured  by  a  firniK'  adjusted 
bandage  or  roller. 

Steriliijation.— When  C;esarean  section  is  performed 
the  uterus  is  preserved,  and  after  convalescence  the  patient 

27 


41 8  /)/sj:as/-:s  or  womex 

is  in  a  position  to  ic-conccivc.  There  may  be  coiulitioiis 
in  which  the  patient  is  desirous  to  prockice  more  chikheii, 
even  with  the  terrible  risk  before  her  of  havin^^  them 
extracted  by  Cicsarean  section. 

On  the  other  hand,  women,  kncnvin^^  the  ^^rcat  risk  they 
run,  ask  that  steps  may  be  taken  to  prevent  what  they  con- 
sickr  a  catastrophe.  This  is  a  very  simple  matter,  and  in 
order  to  sterilize  the  jxilient  the  surgeon  may  perform 
double  oophorectomy,  or  adoj^t  a  simpler  method  and 
pass  two  silk  ligatures  around  each  l^dlopian  tube  by 
transfixing  the  mesosalpinx,  and  after  tying  them  firmly 
divide  the  tube  between  the  ligatures.  Any  measure  short 
of  this  is  useless :  conception  has  on  several  occasions 
taken  place  when  the  tubes  have  been  secured  with  a  single 
thread  on  the  plan  employed  in  the  ligature  of  an  arteiy  in 
continuity. 

The  advantage  of  sterilization  by  ligature  and  di\'ision 
of  the  tube  over  double  oophorectomy  is,  that  young 
patients  are  spared  the  inconveniences  which  almost  always 
result  from  an  artificial  menopause. 

Porro'S  Operation. — This  signifies  the  removal  of  a 
foetus  from  the  uterus  as  in  Cajsarean  section,  followed  by 
hysterectomy. 

In  the  original  method  of  performing  this  operation  the 
abdomen  is  opened,  the  uterus  incised,  and  the  fcetus  ex- 
tracted as  in  Caisarean  section  :  the  uterus  is  then  with- 
drawn through  the  wound  and  encircled  with  the  wire  of 
a  serre-nceud  ;  needles  are  inserted  and  the  uterus  cut  away 
above  the  pins.  The  paiietal  peritoneum  is  then  sutured  to 
the  .stump  below  the  wire  and  the  abdominal  incision 
sutured.  This  clum.sy  method  of  removing  the  pregnant 
uterus  is  now  replaced  by  that  described  under  the  title  of 
supra-vaginal  li\-stert-ctonn-  (p.  411). 

Operations  for  Displacements  of  the  Uterus. — These 

are  of  two  kinds  :  1  l\-steropex\'  (\entro-fixation  ol  the  uterus), 
and  Alexander's  operation  (shortening  the  round  ligaments). 


OPERA'J'IONS    ON   THE    UTERUS.  419 

(4)  Hysteropexy  implies  the  fixation  of  the  uterus  by 
means  of  sutures  to  the  anterior  abdominal  wall.  This 
operation  is  performed  for  two  conditions :  severe  retro- 
flexion of  the  uterus  and  prolapse  of  the  uterus. 

The  instruments  required  are  those  necessary  for  incising 
the  abdominal  wall  as  for  coeliotomy,  plus  some  curved  nee- 
dles of  various  sizes  and  degrees  of  curvature. 

I.  Retroflexion  of  the  Uterus. — The  Steps  of  the  Opera- 
tion.— The  patient  is  prepared  with  the  same  rigid  precau- 
tions as  for  ovariotomy,  and  the  abdomen  is  opened  as  for 
that  operation,  except  that  the  incision  is  shorter.  On 
entering  the  coelom  the  operator  determines  with  his  fingers 
the  position  and  condition  of  the  body  of  the  uterus.  If 
it  be  free,  it  is  then  straightened  and  the  condition  of  the 
ovaries  and  the  tubes  ascertained. 

In  a  fair  proportion  of  cases  of  severe  retroflexion  of  the 
uterus  much  of  the  distress  depends  upon  a  prolapsed 
ovary :  should  the  surgeon  deem  it  necessary  to  remove 
the  painful  ovary  and  tube  in  such  a  case,  he  can  secure  the 
uterus  in  position  by  transfixing  the  stump  by  a  silk  or 
fishing-gut  suture  to  the  peritoneal  edges  of  the  wound : 
in  some  cases  it  may  be  desirable  to  carry  this  restraining 
suture  through  the  muscle  and  fascia  as  well  as  the 
peritoneum. 

When  he  finds  it  undesirable  to  interfere  with  the  ovaries 
or  tubes,  then  with  a  curved  needle,  armed  with  fishing  gut 
or  silk,  he  first  passes  it  through  the  peritoneum  at  the  edge 
of  the  wound,  then  through  the  anterior  surface  of  the  ute- 
rus, and  finally  through  the  opposite  peritoneal  edge :  when 
this  suture  is  tightened  it  will  be  found  to  draw  the  uterus 
to  the  anterior  abdominal  wall,  and  at  the  same  time  ap- 
proximate the  divided  edges  of  the  peritoneum.  If  desir- 
able, two  or  more  sutures  may  be  introduced  (Fig.  115). 
The  rest  of  the  wound  is  then  carefully  closed  in  single, 
double,  or  triple  layers  according  to  the  habit  of  the 
operator. 


420 


DISEASES   OF   WOMEN. 


2.  Prolaf^sc  of  the  Uterus. — When  hysteropexy  is  needed 
for  a  hu'L^e,  bulky,  and  prolapsed  uterus,  the  steps  of  the 
operation  are  tlie  same  as  for  retroflexion,  but  it  is  necessary 
to  introduce  a  greater  number  of  retaininc^  sutures.  Further, 
as  the  uterus  tends  to  slip  downward  into  the  vagina,  it  is 
an  advantage,  as  soon  as  the  fundus  of  the  uterus  is  drawn 
into  the  wound,  to  transfix  it  with  a  stout  suture  cither  of 
silk  or  fishini^  gut,  in  order  that  the  assistant  may  use  itas 
a  holdfast  to  keep  the  uterus  in  position  whilst  the  surgeon 
introduces  the  main  sutures.     In  some  cases  where  the  ute- 


FiG.  115. — Hysteropexy  :  to  show  the  sutures  in  position  (A.  E.  G.). 

rus  is  very  large  it  may  be  requisite  to  employ  four,  five,  or 
even  six  sutures  to  secure  the  uterus  to  the  abdominal 
wall. 

In  all  cases  of  hysteropexy  the  uterus  is  of  necessity  su- 
tured to  the  lower  angle  of  the  wound,  and  is  therefore  in 
close  relation  to  the  bladder.  It  facilitates  the  operation  to 
introduce  the  lowest  sutures  first  and  then  gradually  work 
up  to  the  fundus.  The  wound  is  then  closed  and  dres.sed 
as  described  for  cceliotomy. 

After-treatment. — This  is  comlucted  on  exactly  the  same 
lines  as  after  ovariotomy. 


OPERATIONS   ON   THE    UTERUS.  42 1 

The  Risks. — When  hysteropexy  is  performed  by  sur- 
geons experienced  in  abdominal  work  it  should  have  no 
mortality.  In  a  small  percentage  of  cases  it  has  been  fol- 
lowed by  difficulties  during  labor.  These  risks  are  small 
when  the  attachments  are  made  as  directed  above. 

(5)  Alexander's  Operation :  Shortening  the  Round 
I/igamentS. — The  principle  of  this  operation  consists  in 
exposing  the  round  ligament  of  the  uterus  in  each  inguinal 
canal,  and  shortening  it  so  as  to  straighten  a  retroflexed 
uterus. 

Instruments  required:  Scalpels;  dissecting-forceps  ;  pres- 
sure-forceps ;  scissors ;  needles  and  suture  material ;  re- 
tractors. 

Tlic  Steps  of  the  Operation. — The  patient  is  prepared  and 
placed  in  position  as  for  coeliotomy.  The  skin  is  incised 
as  if  for  the  radical  cure  of  an  inguinal  hernia,  and  the  sub; 
cutaneous  tissues  divided  until  the  intercolumnar  fascia  and 
pillars  of  the  external  abdominal  ring  are  clearly  exposed. 
On  dividing  the  fascia,  the  round  ligament  will  be  seen  as  a 
round  red  cord  lying  in  relation  with  the  genital  branch  of 
the  genito-crural  nerve.  The  ligament  is  now  gently  dis- 
sociated from  the  loose  tissues  in  which  it  lies  imbedded. 
The  ligament  of  the  opposite  side  is  next  exposed. 

As  soon  as  both  ligaments  are  freed  the  assistant  passes 
a  sound  into  the  uterus  and  holds  the  organ  in  its  natural 
position.  The  operator  then  draws  evenly  and  gently  upon 
the  ligaments  until  the  sound  is  moved.  The  ends  of  the 
round  ligaments  are  then  secured  in  the  following  manner: 
A  thin  strand  of  catgut  is  passed  by  means  of  a  curved 
needle  through  one  pillar  of  the  ring,  then  through  the 
round  ligament,  and  finally  through  the  other  pillar :  by 
this  means  when  the  suture  is  tied  it  not  only  secures  the 
round  ligament,  but  at  the  same  time  closes  the  external 
abdominal  ring — the  skin-edges  are  secured  with  thin 
sutures,  and  the  wound  is  then  dressed.  When  the  patient 
is  returned  to  bed  the  knees  are  bent  over  a  pillow. 


422  DISEASES    OE    U'OME.V. 

TIic  wound  is  drcssLcl  at  the  end  of  furty-ei^ht  hours  and 
the  drain-tube  removed.  It  is  customary  to  keep  the  patient 
in  bed  for  three  weeks. 

The  chief  difficulty  experienced  in  this  operation  is  an 
anatomical  one — viz.  the  ready  recognition  of  the  round 
ligament  as  it  issues  from  the  inguinal  canal.  This  is,  as  a 
rule,  a  matter  of  simplicity  to  surgeons  accustomed  to  ope- 
rate on  inguinal  hernia.  It  is  certain  that  man\'  operators, 
not  too  familiar  with  the  anatomical  details  of  the  inguinal 
canal,  have  found  difficulty  in  carrj^ng  out  this  operation 
on  the  lines  introduced  by  Dr.  Alexander. 

Like  the  operation  of  radical  cure  of  inguinal  hernia,  it 
ought  to  be  free  from  risk. 


INDEX. 


Ar.noMiNAi.  distention   after   ovariot- 
omy, 399 
examination,  38,  325 
incision  in  creliotoniy,  382 
hernia,  406 
swellings,  326 
Abscess,  ovarian,  258 
pelvic,  293 
tubo-ovarian,  218 
vaginal,  124 
vulvar,  84 
Accessory  ostium  tuba;,  215 

ovaries,  251 
Adenoma  (Gr.  cuViv,  a  gland)  of  the 
ovary,  265 
of  the  uterus,  207 
Adenomatous   disease  of  the   cervical 
endometrium,  174 
of    the    corporeal    endome- 
trium, 178 
Adhesions,  treatment  of,  390 
Age-changes  in  the  ovaries,  250 
in  the  uterus,  127 
in  the  vagina,  102 
in  the  vulva,  77 
influence  of,  on  sterility,  314 
Alcoholism,    a     contraindication     for 

operation,  334 
Alexander's  operation,  141,  421 
Amenorrhoea  (Gr.  a,  negative  ;  ////i',  a 
month  ;  piu,  to  flow)    301 
concealed.       See     Crypto- menor- 

rha-d.  301,  303 
primary,  301 


Amenorrhnea,  secondary,  302 
Amputation  of  the  cervix  for  cancer, 
370 
for  hypertrophy,  372 
Ana:sthesia,  382 

examination  under,  48,  332 
Anamnesis     (Gr.  ava,  anew  ;    fivrjaic, 

memory),  in  diagnosis,  318 
Anatomy  of  the  Fallopian  tube,  18 

of  the  ovary,  17 

of  the  pelvic  peritoneum,  26 

of  the  uterus,  19 

of  the  vagina,  20 

of  the  vulva,  21 
Anteflexion  of  the  uterus,  128 
Anteversion  of  the  uterus,  128 
Apoplexy  of  the  ovary,  256 
Arteries,  ovarian,  23 

uterine,  anatomy  of,  24 

in    abdominal   hysterectomy, 

413 
in  amputation  of  the  cervix, 

372 
in  vaginal  hysterectomy,  374 
vaginal,  25 
vulvar,  25 
yVscites,  diagnosis  of,  283 
Atresia  (Gr.  a,  negative;  TETpnivu,  to 
perforate)  of  the  cervix,  68 
of  the  cervix,  operation  for,  358 
of  the  OS  externum,  68,  72 
of  the  OS  internum,  68,  72 
of  the  vagina,  68,  71 
operation  for,  357 
J23 


424 


INDEX. 


Atropliy  ((Jr.  urjiii(*>/a,  want  of  iiuiir- 
islimcnt)  of  the  ovary,  250 

of  the  uterus,  146 

of  the  vagina,  102 

of  the  vulva.  See  A'raurosis,  89 
Axial  rotation  of  ovarian  tumors,  275 

r.ACiM.i's  (L.  bacilliivi,  a  little  rod), 
vaginal,  112 

I!e<l-sores  after  ovariotomy,  401 

liimanual  examination,  40 

Bladder-distention,  diagnosis  of,  283 

Bladder-injuries,  during  abdominal 
operations,  402 

Bladder-symptoms,  322 

Bowels,  regulation  of,  after  ovariot- 
omy, 400 

Broad  ligament.  See  Mesovictritiiii, 
27 

CiT-SAREAN  section,  416 
Calcification  of  corpora  lutea,  256 

of  foetus.     See  Lithopcrdion,  239 
of  myomata,  187 
Canal  of  Nuck,  anatomy  of,  28 

hydrocele  of,  loi 
Carcinoma  of  the  body  of  tht  uterus, 
212 
of  the  cervix,  208 
of  the  Fallopian  tube,  223 
of  the  ovary,  263 
of  the  vulva,  99 
Caruncle,  urethral,  93 

removal  of,  by  cauter)%  348 
by  dissection,  347 
Carunculnc  hymenales  (L.  canturiiln, 
dim.  of  loro,  flesh  ;  hymen),  92 
myrtiformes  (L.  myrtuni,  a  myr- 
tle-berry; forma,  shape),  92 
Catheter,  cleansing  of,  400 
mode  of  passing,  400 
Catheterization  after  ovariotomy,  400 


Cauterization    of     unlhral     caruiK-lc, 

348 
Cervix     uteri    (L.   cen'ix,  the    neck  ; 
uterus,  Khii  womb),  adeno- 
matous disease  of,  174 
amputation  of,  370 
anatomy  of,  20 
atrophy  of,  146 
carcinoma  of,  208 
epithelioma  of,  206 
erosion  of,  174 
hypertrophy  of,  141 
laceration  of,  160 
repair  of.      See    Trachelor- 
rhaphy. 
Cicatricial  union  of  the  labia,  356 
Cicatrix,  cancer  of,  407 

yielding,  406 
Clitoris    (Gr.  K/urofur,  from    wAe/f,  a 
key),  anatomy  of,  21 
elephantiasis  of,  93 
epithelioma  of,  93 
inflammation  of,  93 
removal  of,  348 
Cceliotomy     (Gr.    Koi/ia,    the    belly; 

TE/ivu,  to  cut),  379 
Colpocleisis   (Gr.  K(»/.7rof,  the  vagina; 

KAfiGiC,  a  shutting  up),  355 
Colpo-perincorrhaphy,  351 
Colporrhaphy  (Gr.  /«5^T0f,  the  vagina; 
im(j)f/,  a  seam),  anterior,  351 
posterior,  350 
Colpotomy    (Gr.  s6?.7rnt;,  the   vagina; 
Tt/ivu,  to  cut),  anterior,  376 
posterior,  377 
Conception,  retention   of  products  of, 

165 
Confinements,  history  of.  in  diagnosis, 

319 

Conical  cervix,  61 

Constitutional    disease,  a    contraindi- 
cation for  operation,  334 


INDEX. 


425 


G^ipura  librosa,  256 
Ciirpu.s    lutcum    (1..   corpus,  a    body; 
luteuiii,   yellowisli),    anat- 
omy of,  11 
calcified,  256 
cystic,  256 
diseases  of,  255 
Crilniform  hymen,  92 
Crutch  for  lithotomy  position,  336 
Cryptomenorrhtea    ((ir.   /fpvrrruc,  hid- 
den ;    ////I',   a    month ;     poia,   a 
flow),  71,  303 
Curette,  360 
Curetting,  360 
Cyclical   theory  of  menstruation   (Gr. 

KVKT^LKoq,  circular),  36 
Cyesis  (Gr.  kvi^olq,  pregnancy).     See 

Pregnancy,  194 
Cystitis    (Gr.  kvot/.c,  the   bladder),  a 

cause  of  pruritus,  87 
Cystocele  [Kvang;  k?/!?;,  a  tumor),  103 

operation  for,  351 
Cysts,  Bartholinian,  99,  349 
dermoid,  265 
Gartnerian,  125,  271 
of  hymen,  92 
of  Morgagni,  53 
mucous,  99,  125 
ovarian,  261 
papillomatous,  269 
parovarian,  270 
periurethral,  126 
retention,  213 
sebaceous,  99 
of  vagina,  1 25 
of  vulva,  99 

Decidua    (L.  decido,  to    fall    down 
from),  menstrual,  311 
uterine,  in  tubal  pregnancy,  236 
Decidual  cells,  204 
Deciduoma  malignum,  202 


Dehiscence  of  the  ovum   (L.  dchisco, 

to  split  open),  33 
Dermoids  (Gr.  dtfyjia,  the  skin ;  tidoc. 

likeness),  265 
Development  of  the  generative  organs, 

51  . 
Diabetes  a  cause  of  pruritus,  87 

a  contraindication  for  operation, 

334 

Dilatation  of  the  cervix,  359 
dangers  of,  363 
of  the  vagina,  313 

Diplococcus  of  Neisser.  See  Gono- 
cocczis,  115 

Discharges  from  female  genital  pas- 
sages, 117 

Discus  proligerus  (L.  discus,  from  (ir. 
iViGKoc,  a  quoit ; p7-oles,  offspring ; 
gero,  to  bear),  33 

Displacements    of     Fallopian     tubes, 

215 

of  ovaries,  251 

of  uterus,  128 

of  vagina,  103 
Drain,  Mikulicz,  385 
Drainage,  in  coeliotomy,  384 
Dressings  for  abdominal  wounds,  384 
Dysmenorrhcea     (Gr.    (5i'f,   with    dif- 
ficulty; liiiv;  fwia),  306 

constitutional,  307 

in    flexions   of    the    uterus,    128, 

309 

local,  308 

membranous,  310 
Dyspareunia      (Gr.    dixyTrnpevvnc,    ill- 
mated  ;   from  (^i^c ;  Trapcvvoc.  a 
bed-fellow),  313 

EciiiNococci'S  colonies  in  the  Fallo- 
pian tubes,  299 
in  the  mesometriuni,  298 
in  the  omentum,  298 


426 


INDEX. 


Kcliiiiococcus   culonics   in    tlit-    jiclvis, 

in  the  uteiiis,  214,  29iS 
in  the  vagina,  126 
secondary  infection  by,  299 
Ectopic    gestation     (Gr.   iKrozftq,   dis- 
placed).    See    Tubal  Gesta- 
tion, 229 
l-'-lytrorrhaphy  (Cir.  l7.v-pov,  a  slicath, 
the  vagina ;  /mi^/),  a  seam).    See 
Colporrhaphy. 
Endometritis  (Gr.  Ivi^uv,  witliin ;  itl/rfta, 
the  womb),  acute,  169 
cervical,  174 
chronic,  172 
corporeal,  178 
glandular,  172 
hremorrhagic,  173 
interstitial,  173 
puerperal,  170 
Endometrium,    adenomatous     disease 

<.r,  174 

anatomy  of,  168 

diseases  of,  168 

morphology  of,  168 
Enterocele     (Gr.    ivrepov,    intestine ; 

K//?i^,  a  tumor),  107 
Enucleation  of  broad   ligament  cysts, 

.S93 
of  myomata,  abdominal,  414 

vaginal,  363 
of  sessile  ovarian  cysts,  393 
Epithelial     infection    of     peritoneum. 

289 
Epithelioma  of  clitoris,  93 
of  cervi.v  uteri,  206 
of  vagina,  125 
of  vulva,  97 
Erosion  of  the  cervix.     See  At/enom- 

atous  Disease  of  Cervix,  174 
Evacuation  of  the  cyst  in  ovariotomy, 
390 


ExamiMatiiin,  abdominal,  38,  325 

bimanual,  40 

recto-abdominal,  40 

under  an  aniesthetic,  48,  332 

vaginal,  39 
Excision  of  tumors  of  the  labia,  349 

of  urethral  caruncle,  347 
Exstrophy  of  the  1  la<lder,  58 
Extrauterine   gestation.     See    Tubal 
Gestation,  229 

Fai.H)I'IAN    tubes    (after   the    anato- 
mist  Falloiiius),  adenoma 
of,  222 
anatomy  of,  18 
carcinoma  of,  223 
development  of,  53 
displacements  of,  215 
echinococcus     colonies     of, 

299 
hernia  of,  215 
inllammation  of,  215 
malformations  of,  215 
myoma  of,  222 
papilloma  of,  222 
pregnancy  in,  229 
removal  of,  395 
sarcoma  of,  222 
sclerosis  of,  220 
tumors  of,  222 
False    ]iassages    during  dilatation  of 

the  cervi.x,  363 
Family  history  in  diagnosis,  31S 
Fatty  degeneration  of  myomata,  1S7 
Fibrocystic  tumors  of  uterus,  187 
Fibroids    of    uterus.      See     Myoma, 

iSi 
Fibroma  of  the  ovary.  261 
Fibro-myoma.     See  Afyoina,  1 81 
Fimbrix     (L.    /niibriir,   threads)     of 
Fallopian   tube,  anatomy  of,  18 
inversion  of,  217 


IXDRX. 


427 


l'iml)iiat(.'(i     cxlrcinily    nf     I'lilldpiau 

tulu',  occlusion    of,  216 
I'istula  (L.  fistula,  anytliins::;  tubular), 
alKlomiiial,  406 
detection  ot",  109 
operations  for,  352 
recto-vaginal,  109 
treatment  of,  352 
uretero-vaginal,  109 
urethro- vaginal,  109 
utero- vesical,  109 
vesico-vaginal,  109 
Flushing  curette,  360 
Foreign  bodies  left  in  abdomen,  404 

in  vagina,  108 
Fourchette     (Fr.  foii7-chette,   a    small 
fork;    \^.  fiirca,3i  fork),  anat- 
omy of,  21 
laceration  of,  95 

Gartner's  duct,  anatomy  of,  18 

cysts  of,  125,  271 
Genu-pectoral  position,  41 
Glands  of  Bartholin,  abscess  of,  84 
anatomy  of,  23 
cysts  of,  99 
uterine,  169 
Glandular  endometritis,  172 
Gonococcus,  characters  of,  115 
Gonorrhoea  (Gr.  yovnr,  semen;  poia,  a 

flow).  Si,  iiS 
GonorrhcL-al  endometritis,  169 
salpingitis,  215 
urethritis,  8 1 
vaginitis,  1 19 
vulvitis,  81 
Graafian  follicle  (after  von  Graafe,  the 
anatomist;  \..  folliciilns,  a  liltk' 
bag),  ZZ 
Gynecological  o]Derations,  333 


II/i:matocki.f,  (Gr.  hnm,  li 
a  tumor),  234 


A/////, 


I  heniatocolpos    (Gr.   uijia;    KoATror,   a 
recess,  the  vagina),  68 
lateral,  75 

operation  for,  74,  356 
Ilamatoma  of  broad  ligament,  235 

of  vulva,  80,  loi 
I  laniatometra    (Gr.  ai/ui;    iiI/tjiu,  the 
womb),  68,  73,  214 
operation  for,  75,  358 
Iliximatosalpinx    (Gr.   Uijia;    r,d7.iny^, 
a  trumpet,  the  Fallopian  tube), 
68 
Hcemato-trachelos  (Gr.  a//<«;  r/)fl;j;£/lor, 

the  cervi.x),  68 
Iloimophilia,    a    contraindication    for 

operation,  334 
Hemorrhage  after  ovariotomy,  403 
Hermaphrodism    (Gr.    'Ep//?/f,    Mer- 
cury,   representing     the     male 
part ;  'A(piw(ViTii,  N'enus,  repre- 
senting the  female  part),  49 
Hernia    (L.  hernia,  a    rupture),  ab- 
dominal, 406 
inguinal,  loi 
of  Fallopian  tube,  215 
of  pelvic  floor,  103 
vaginal,  107 
ventral,  406 
Homology  of  male   and   female  gen- 
erative organs,  55 
Hottentot  apron,  78 
Hydatids.     See    Ecliinococnis     Colo- 
nies, 297 
Hydramnion,  diagnosis   from   m\onia, 

195 
Hydrocele    (Gr.  iky(.)p,  water;    ii!f/7i,a. 

tumor),  of  the   canal  of  Nuck, 

101 
ovarian,  272 
llvdromctra     (Gr.    i'(^(.</) ;    H'lrpa,  the 

womb),  214 
1  lytlroperitoneum,  290 


428 


INDEX. 


Hydrops  tulnv  prolliK-ns,  219 
Hydrosalpinx     (Gr.    ir'w/j ;     ooatt/)^, 
the  Fallopian  tube),  218 
intermitting,  219 
Hymen  (Gr.  v\iijv,  a  thin  membrane), 
anatomy  of,  22 
caruncles  of,  92,  93 
cysts  of,  92 
imjierforate.     See  Atresia  of  the 

Vagina,  59 
ru])ture  of,  93 

variations  in  shape  and  structure 
of,  92 
Hypertrophy  of  the  cervix,  supravagi- 
nal, 141 
vaginal,  144 
of  the  labia  minora,  78 
of  the  uterus,  141 
Hysterectomy  (Gr.  i'CTr//j«,  the  womb; 
iKTonjj,  a  cutting  out),  41 1 
supravaginal,  411 
total  (pan-hysterectomy),  414 
vaginal,  373 
Hysteria,  259 

Hysteropexy  (Gr.  varipa;  nyiic,  fast- 
ening), for  prolapse,  420 
for  retroflexion,  419 

Impaction  of  gravid  uteru?,  195 
of  myomata,  1S8 
of  ovarian  tumors,  278 
Imperforate  hymen,  59,  93 
ojieration  for,  355 
Incision,  abdominal,  382 
closure  of,  383 

by  triple  method,  384 
Incomplete  ovariotomy,  394 
Indammation  of  the  F'allopian  tulxs, 
215 
of  the  ovaries,  257 
of  the  jiclvic  ]H'ritoneum,  28S 
of  the  pelvic  cellular  tissue,  292 


Inllnmmation  of  the  uterus,  169 

of  the  vagina,  118 

of  vulva,  80 
Injuries  of  the  bladder,  402 

of  the  intestine,  402 

of  the  ureter,  402 

of  the  uterus,  160,  403 

of  the  vagina,  107 

of  the  vulva,  79 
Insanity  after  ovariotomy,  405 
Instruments  for  diagnosis,  41 

for  operation,  338,  380 

sterilization  of,  333,  339 
Intermitting  hydrosalpinx,  219 
Intestinal  obstruction  after  ovariotomy, 

405 
Intestine,  injury  of,  402 
Inversion  of  the  uterus,  153 
Irrigation  in  ca-)iotomy,  384 

Kobelt's  tubes,  18 

Kraurosis  vulvae  (Gr.  Kpavpo^,  dry),  89 

Lai:ia  MAJORA  (L. /<7/'///w,  a  li]);  f/ia- 
jtis,  greater),  abscess  of,  84 
anatomy  of,  21 
cicatricial  union  of,  356 
cysts  of,  99 
ba-matoma  of,  80 
minora  (L.  miitius,  smaller),  an- 
atc)my  of,  21 
hypertrophy  of,  78 
See  also  I'uho. 
Laceration  of  the  cervix,  160,  368 

of  the  perineum,  95 
Laparotomy    (Gr.   T^nTrdpa,  the    flank, 
from  ?M~ap6c,  soft ;    Ttfivu,  to 
cut),  379.     See  Caliotomy. 
I.eucocythcemia,  a  contraindication  for 

operation.  334 
l.eucorrha-a    (Cir.  ^fi'AT^c,  white  ;  ptna, 
a  flow)  a  cause  of  pruritus,  87 


LXPEX. 


429 


Leucorrlinea,   value    of,    in    diai^iKi.sis, 
322 

varieties  of,  1 17 
L-eukuj)lakia  of  the  vulva,  86. 
Ligameiils,  broad.    See  A/csoiiuiriiiin, 
27 

ovarian,  17 

round,  20 

utero-sacral,  27,  28 
Ligature,  fate  of,  406 

material,  380 

versus    clamps    in    hysterectomy, 

375 
Litliopirdion  (Gr.  '/dOoc,  a  stone  ;   ndic, 

a  child),  239 
Liver,  diagnosis  of  enlargements  of,  284 
Lymphatics  of  the  genital  organs,  26 

Malaria,  a  contraindication  for  ope- 
ration, 334 
Malformations  of  the  external  genital 
organs,  49 
of  the  Fallopian  tubes,  215 
of  the  hymen,  92 
of  the  ovaries,  251 
of  the  uterus,  61 
of  the  vagina,  59 
of  the  vulva,  49 
Membrana  granulosa,  ^^ 
Membranous  dysmenorrhea,  310 
Menopause  (Gr.  ^J]v,a.  month  ;   navaic, 

a  stopping  naturally),  37 
Menorrhagia  (Gr.  jxtp,  a  month  ;  /i;);  - 

will,  to  burst  forth),  304 
Menstrual  blood,  characters  of,  31 

retained,  characters  of,  76 
Menstruation  (L.  tnctistnmlis,  month- 
ly), absence  of.     See  Amenor- 
rhea, 301 
anatomy  of,  31 

cessation  of.     See  Menopaitsc,  37 
clinical  features  of,  30 


Menstruation,   concealed.     Sec   Cryp- 
(oinenorr/ia-a,  303 
cyclical  theory  of,  36 
in  diagnosis,  319 
in  relation  to  operation,  335 
ovular  theory  of,  36 
painful.    See  Dysmcnorrhcua,  306 
physiology  of,  31 
profuse.      See  Meiiorrhai^ia,  304 
significance  of,  36 
Mcsometric  gestation,  235,  409 
Mesometrium  (Gr.  Hfuof,  middle;  jirj- 
Tpa,  the  womb),  abscess  of,  293 
anatomy  of,  27 
cysts  of,  270,  271 
echinococcus  colonies  in,  298 
inflammation  of.     See  Pelvic  Cel- 

hditis,  292 
lipomata  of,  296 
myoma  of,  296 
sarcomata  of,  297 
Mesonephric  ducts,  51 
Mesonephros   (Gr.  jiiaoc,;  ve<pp6r,  kid- 
ney), 51 
Mesosalpinx  (Gr.  /j-egoc;;  ad?.nt)^,  the 

Fallopian  tube),  28 
Metritis  (Gr.  /u?'/Tpa,  the  womb),  acute, 
169 
cervical,  174 
chronic,  172 
corporeal,  178 
interstitial,  173 
parenchymatous,  1 70 
Metrorrhagia  [Gr.  jmI/t pa;  jvi)i'viu,  to 

burst  forth),  304 
Metrostaxis    (Gr.    ftZ/Tpa;     ard^u,    to 

flow  drop  by  drop),  401 
Mikulicz  drain,  385 
Miscarriages,  history  of,  in  tliagnosis, 

319 
Monilia  Candida  in  the  vaginal  secre- 
tion, 112 


430 


IM>1:X. 


Mons  N'cncris,  2i 
Murccllcnient  of  inyoniata,  366 
Mucoid  deycmralion  of  inyomata,  1S7 
Mucosa  (1-.  iiiitcosus,  slimy),  ult-riiic, 
35.  i^S 
cliangt'S  during  iiK-iislruulioii,  J5 
Mucous    inciiibraiic.      See    Eitdatne- 
/  rill  1)1,  16S 
polypus,  201 
Miillers  duct,  52 

Mumps  in  relation  to  oophoriiis,  257 
My<ima   (Gr.  jxix,  muscle)  ol  the  hal- 
lopian  tube,  222 
of  the  mesomelrium,  297 
of  the  ovarian  ligament,  297 
of  the  ovary,  261 
of  the  round  ligament,  296 
uterine,  degenerations  of,  187 
impaction  of,  188 
interstitial,  182 
operation   for  pedunculated, 

364 
for  sessile,  364 
septic  infection  of,  1S7 
submucous,  184 
subserous,  186 
with  pregnancy,  189 
Myomectomy,  abdominal,  415 
by  morcellement,  366 
vaginal,  363 

Nkedles,  pedicle,  388 
Nerves  of  the  genital  organs,  26 
Nyniphai  (Gr.  vu/t<pT/,  a  bride;  the  ex- 
ternal organs  of  generation   in 
female).      See    Labia  Minora, 


Obesity,  diagnosis   from  ovaiian  tu 

mors,  28 1 
Occlusion  of  the  cervical  canal,  68 
of  the  ostium  tub;v,  216 


( )cclu.sioii  <)(  the  vagina,  59,  68 
( )ophorectomy  (Gr.  Luv;  tjHt/iiu;  Ikto- 
fii/,  a  cutting  out),  395 
for  diseased  appendages,  228,  395 
for  nerve  troubles,  396 
for  ovarian  disease,  396 
for  uterine  myoma,  396 
Oophoritis,  257 
Oophorocele,  253 

Oophoron  ( Gr.  ciuv,  an  egg ;  9'^"  u,  to 
bear),  anatomy  of,  1 8 
cysts  of,  263 
inllammation  of,  257 
See  also  Ovary. 
Oosperm  (Gr.  ciov,  an  egg;  O'ljinn,  a 

seed),  229 
Operation  table,  382 
Ophthalmia,  a  complication  of  gonor- 

rlitea,  123 
Os  uteri,  20 

Ostium  tubce,  accessory,  215 
occlusion  of,  216 
stenosis  of,  221 
Ovarian  abscess,  258 
arteries,  23 
concretions,  256 
hydrocele,  272 
ligament,  anatomy  of,  1 7 

tumors  of,  297 
neuralgia,  259 
pouch,  28 
Ovariotomy,  387 

after-treatment  of,  399 
anomalous,  394 
during  pregnancy,  287 
incomplete,  394 
repeated,  395 
trocar,  387 
Ovary    (L.  ovariiivi,  an    egg  kee|)er, 
from   in'uiii,   an    egg),   abscess 
of,  258 
absence  of,  251 


JA'DEX. 


43' 


( )v;uy,  accessory,  25 1 

adenoma,  of,  265 

age-chaiigcs  ol,  250 

anatomy  of,  17 

apojjlexy  of,  256 

atrophy  of,  250 

carcinoma  of,  263 

cirrliosis  of,  259 

cysts  of,  263 

dermoids  of,  265 

displacements  of,  251 

enlarged,  255 

fibroma  of,  261 

fibrosis  of,  257 

hernia  of,  252 

inllammation  of,  257 

malformations  of,  251 

myoma  of,  261 

pajjilloma  of,  269 

prolapse  of,  254 

sarcoma  of,  262 

supernumerary,  251 

tuberculosis  of,  258 

tumors  of,  261 

axial  rotation  of,  275 
differential  diagnosis  of,  281 
impaction  of,  27S 
rupture  of,  276 
septic  changes  in,  273 

undescended,  252 
Ovula   Nabothii    (L.  oviiiiii/t,  dim.  of 

ovum,  an  egg),  169 
Ovulation,  31 

deficient,  315 

theory,  36 

I'ain,  value  of,  in  diagnosis,  321 
I'anhysterectomy       (Gr.     tti';/',     total  ; 

varifja;  eKTnfiif),  414 
Papilloma  of  the  Fallopian  tube,  222 

of  the  ovary,  269 

of  the  peritoneum,  222 


I'apiUoma  of  the  vulva,  97 
Parametritis  (Gr.  najm,  beside  ;  /i/'/tiki, 
the  wombj.     See  Pi:lvic  Ccllu- 
lilis,  292 
l'aroo[)lioron   (Gr.  ntiixi,  beside;   cjod; 
il>tijn:u),  anatomy  of,  18 
cysts  of,  269 
Parotitis  after  ovariotomy,  405 
Parovarian  cysts,  270 
Parovarium  (Trapa,  beside  ;  ovarium), 

anatomy  of,  18 
Pedicle,  ligature  of,  391 
needles,  388 
treatment  of,  391 
twisted,  275 
Pelvic  abscess,  293 
cellulitis,  292 
peritoneum,  anatomy  of,  26 

epithelial  infection  of,  289 
septic  infection  of,  288 
tuberculosis  of,  291 
peritonitis,  288 
tumors,  diagnosis  of,  331 
Perimetritis    (Gr.  ~£/",  round;   jii/Tfui, 
the  womb),  288 
septic,  288 
serous,  289 
Perineal  body,  95 

Perineorrhaphy   (Gr.  -mpUxuin';  pnipi/, 
a  seam),  341 
for  complete  rupture,  345 
for  partial  rupture,  342 
Perineum    (Gr.  Tz^invninv,  lit.  the   sur- 
rounding district),  anatomy  of, 

94 
repair  of,  341 
rupture  of,  95 
IVritxiphoritis   (Gr.  ■Kepi,  round;    uov, 

<:,n,,h.>),  258 
Peritoneum     (Gr.    to    Trepiruvaiov,   lit. 
that   which  is  stretched  over). 
See  Peh'ic  Peritoneum,  2S8 


432 


INDEX. 


IVritonilis  after  ovariotomy,  403 
septic,  28S 
serous,  289 
tubercular,  291 
I'eri-urethral  cysts,  126 
I'essaries  (Low  V,.  pessariuni,  from  Gr. 
neaauc,  an    oval  shaped    stone 
for   playing   a    game    like    our 
draughts;  afterward  a  plug  of 
linen,    resin,    etc.    for     vaginal 
medication),   147 
Pessary,  Hodge,  134,  148 
retained,  151 
ring,  148 
vaginal  stem,  150 
riianlom  tumor,  282 
riiysicul    examination     in    diagnosis, 

325 
Pinhole  OS,  61 
Placenta,  retained  portions  of,  165 

tubal,  236 

treatment  of,  247 

uterine,  236 
Placental  polypus,  201 
Polypus  (Gr.  iro?.!;,  many;  nov^,  foot), 
cervical,  201 

fibroid,  201 

malignant,  20I 

mucous,  201 

operation  for,  364 

placental,  20I 
Porro's  operation,  418 
Pouch  of   I)oughis.     See    Recto-vagi- 
nal I-'ossa,  27 
Pregnancy,  cornual,  196 

diagnosis  of,  from  myoma,  193 

diseases  arising  from,  163 

extra-uterine,  229,  40S 

mesometric,  236 

normal,  signs  of,  194 

spurious,  282 

tubal,  229,  408 


Pregnancy,  witli  carcinoma  of  the  cer- 
vix, 211 

with  myoma,  1 89 

with  ovarian  tumor,  2S5 
Preparation  of  patients  for  operation, 

335,  379 
Pressure- forceps  in  hysterectomy,  375 
Primary  sexual  characters,  49 
Procidentia  of  the  uterus,  136 
Prolapse  of  the  ovary,  254 
of  the  uterus,  136 
of  the  vaginal  walls,  103 
Pruritus  vulva;,  87 
Pseudocyesis    (Gr.  ■^evdoq,  false ;  kv- 

ijcir,  pregnancy),  ?82 
Pseudo-hermaphrodism,  49 
Puberty  (L./«ii^«,  youth),  onset  of,  30 
Pulse  after  ovariotomy,  401 
Pyocolpos  (Gr.  ■ttvov,  pus;  ko/.-^w,  the 

vagina),  70 
Pyometra     (Gr.     ttvov;      /w'/"^'rt,    the 

womb),  70,  214 
Pyosalpinx    (Gr.   ixvov;   cakni-)^,  the 

Fallopian  tube),  70,  217 

Reci  Ai,  examination,  40 

symptoms,  322 
Rectocele  (L.  rectum^  the  bowel;  Gr. 

K-ip.il,  a  tumor),  103 
Recto- vaginal  fossa,  anatomy  of,  27 
Remote  effects  of  ovariotomy,  407 
Renal  disease,  a  contraindication  for 
ojx-ration,  334 

tumors,  di.'igno>is  of,  284 
Keposilor,  uterine,  157 
Retained  menstrual  jiroducts,  68 

pessary,  151 

products  of  conception,  165 
Retroflexion  of  the  uterus,  129 
Retroversion  of  the  uterus,  131 

of  the  gravid  uterus,  195 
Reversible  tenacula  force|)s,  369 


INDEX. 


433 


Rheumatism,  a  complication  of  gon- 

orrluva,  1 23 
KouirI  iii^'ainciit  of  the  uterus,  anat- 
omy of,  20 
shortening  of,  421 
tumors  of,  296 
Rupture  of  ovarian  cysts,  276 
tubal,  diagnosis  of,  241 

primary,  extra-peritoneal,  235 

intra-peritoneal,  234 
secondary,    extra-peritoneal, 

239 
intra-peritoneal,  238 
treatment  of,  245,  408 

Salpingitis  (Gr.  aakiny^,  a  trumpet, 
the  Fallopian  tube),  215 
acute,  215,  224 
chronic,  220,  225 
gonorrhceal,  215 
septic,  217 
tubercular,  220 
Salpingocele    (Gr.    aakiri-y^;    kt]}.)],    a 

tumor),  215,  253 
Salpingo-oophorocele,  253 
Sarcoma,  decidual,  202 

of  the  Fallopian  tube,  222 
of  the  ovary,  262 
of  the  uterus,  202 
of  the  vagina,  124 
of  the  vulva,  97 
Secondary  sexual  characters,  49,  407 
Secretions,  normal,  1 1 1 
pathological,  114 
uterine,  II 4 
vaginal,  ill 
Semiprone  (Sims')  position,  41 
Septic  infection  (Gr.  ar/TrriKoc,  putrid) 
of  myoniata,  187 

of  ovarian  tumors,  273 
of  peritoneum,  288 
of  retained  menses,  74 
28 


Sessile  myomata,  treatment  of,  364 

ovarian      cysts,      treatment      of, 

393 
Shock  after  ovariotomy,  402 
Shot-and-coil  sutures,  345 
Sound,  uterine,  41 
Speculum,  Auvard's,  47 

Cusco's,  47 

Fergusson's,  46 

Neugebauer's,  47 

Sims',  47 
Spleen,  diagnosis  of  enlargements  of, 

284 
Sponge-holders,  388 
Sponges,  preparation  of,  381 
Stenosis  (Gr.  arevoc,  narrow)  of  the  os 
externum,  61 

of  the  OS  internum,  309 

of  the  ostium  tuba:,  221 

of  the  vagina,  59 
SteriHty,  314 

treatment  of,  316 
Sterilizer,  339 
Sterilizing  of  instruments,  ^^;i 

of  patient  during  Csesarean  sec- 
tion, 417 
Subinvolution  of  the  uterus,  164 
Superinvolution  of  the  uterus,  163 
Supernumerary  ovaries,  251 
Suppuration     of     Bartholinian    cysts, 

99 
of  ovarian  cysts,  273 
Suture  material,  380 
Sutures,  removal  of,  401 
Symptoms,  value  of,  in  diagnosis,  318 

321 

Table  for  operating,  382 
Tampons,  glycerin,  172,  1 78 
Temperature  after  ovariotomy,  400 
Tenacula  forceps,  reversible,  369 
Tents,  47 


434 


INDEX. 


Tetanus  after  ovariotomy,  404 
Trachelorrhaphy    (Gr.    rpaxtkor^,   the 
neck,     the     cervix ;     /)o?>//,    a 
seam),  368 
Trendelenburg  position,  3S2 
Trocar,  ovariotomy,  387 
Tubal  abortion,  232 
gestation,  229 

operation      for,     after     fifth 
month,  409 
after  rupture,  409 
at  the  time  of  rujUure, 
40S 
rupture    of,   primary    extra- 
j)eritoneal,  235 
intraperitoneal,  234 
secondary,  extraperito- 
neal,  239 
intra-peritoneal,  238 
mole,  231 
Tuberculosis  of   the    Fallopian   tube, 
220 
of  the  ovary,  258 
of  the  jieritoneum,  291 
of  the  uterus,  179 
of  the  vulva,  86 
Tubo-ovarian  abscess,  218 
cyst,  219 
ligament,  19 
Tulx)-uterine  gestation,  239 
Tumors  of  the  broad  ligament,  296 
of  the  Fallopian  tubes,  222 
of  the  mesometrium,  296 
of  the  ovarian  ligament,  297 
of  the  ovaries,  261 
of  the  round  ligament,  296 
of  the  uterus,  181 
of  the  vagina,  124 
of  the  vulva,  97,  349 
Twin  tubal  pregnancy,  229 
Twisted    pedicle.     See    Axial   Rota- 
tion, 275 


UNDESCENDF.n  OVARIES,  252 
Ureter,  injury  of,  402 
Uretero-vaginal  fistula,  109 
ojK'ration  for,  354 
Urethra,  diseases  of,  93 
Urethral  caruncle,  93 

operations  for,  348 
Urethro- vaginal  fistula,  109 

operation  for,  355 
Uro-genital  sinus,  51 
Uterine  arteries,  24 

changes  in  menstruation,  34 
lymphatics,  26 
mucosa,  35,  168 
nerves,  26 
probe,  171,363 
repositor,  158 
souffle  in  myomata,  193 
in  pregnancy,  194 
sound,  41 
veins,  25 
Utero- vesical  fistula,  355 

fossa,  28 
Uterus  (L.  uterm,\ht.  womb), absence 
of,  6r 
adenoma  of,  207 
age-changes  in,  127 
anatomy  of,  19 
anteflexion  of,  128 
anteversion  of,  128 
atrophy  of,  146 
bicornis,  63 
carcinoma  of,  207 
didelphys,  64 
displacements  of,  128 
echinococcus  colonies  of,  214,  298 
epithelioma  of,  206 
fibroniyoma  of,  l8l 
Hexions  of,  128 
hypertrophy  of,  I4I 
infantile,  61 
intlammations  of,  168 


INDEX. 


435 


Uterus,  injuries  of,  i6o 
inversion  of,  153 
measurements  of,  127 
myomata  of,  iSi 
perforation  of,  163 
procidentia  of,  136 
prolapse  of,  136 
retroflexion  of,  129 
retroversion  of,  131 
rudimentary,  6 1 
sarcoma  of,  202 
septus,  63 
single-horned,  62 
subinvolution  of,  164 
superinvolution  of,  163 
tuberculosis  of,  179 
tumors  of,  1 81 
unicornis,  62 

Vagina  (L.  vagina,  a.  sheath),  abscess 
of,  124 
absence  of,  59 
age-changes  in,  102 
anatomy  of,  20 
atresia  of,  59,  68,  122 
operation  for,  357 
cysts  of,  125 
diseases  of,  102 
displacements  of,  103 
double,  60 

echinococcus  colonies  of,  126 
epithelioma  of,  125 
tistulse  of,  109 
foreign  bodies  in,  108 
hernia  of,  107 
infection  of,  in 
inflammation  of,  1 18 
injuries  of,  107 
malformations  of,  59 
normal  secretion  of,  in 
sarcoma  of,  124 
secretions  of,  in 


Vagina,  stenosis  of,  59 

tumors  of,  124 
Vaginal  bacillus,  II 2 

examination,  39 

hysterectomy,  373 

myomectomy,  363 
Vaginismus,  312 
Vaginitis,  gonorrhoeal,  119 
in  children,  119 
in  pregnant  women,  120 

senile,  119 

septic,  119 

simple,  118 
Veins,  ovarian,  25 

uterine,  25 

vaginal,  25 

vulvar,  25 
Ventrofixation  of  the  uterus,  419 
Vesical  symptoms,  322 
Vesico-vaginal  fistula,  109 
operation  for,  352 
Vestibule,  23 
Visceral    disease,  a     contraindication 

for  operation,  334 
Volsella,  44 

Vomiting  after  ovariotomy,  399 
Vulva   (L.  vulva,  the  female  external 
genitals),  abscess  of,  84 

age-changes  of,  77 

anatomy  of,  21 

angeioma  of,  97 

atrophy  of.     See  Kraurosis,  89 

carcinoma  of,  99 

congestion  of,  87 

cysts  of,  99 

eczema  of,  85 

elephantiasis  of,  86 

epithelioma  of,  97 

erysipelas  of,  Zt, 

gangrene  of,  84 

ha;matoma  of,  80 

herpes  of,  85 


436 


INDEX. 


Vulva,  liypcrtropliy  of,  78 
inflainination  of,  80 
injuries  of,  79 
irritation  of,  87 
kraurosis  of,  89 
lipoma  of,  97 
lupus  of,  86 
malformations  of,  49 
myxomata  of,  97 
<L'dema  of,  83 
papillomata  of,  97 
sarcomata  of,  97 
syphilis  of,  86 


Vulva,   tulierculosis   of.     See   Lupus, 
86 

tumors  of,  97 

varix  of,  79 

warts  of,  97 
Vulvitis,  gonorrhccal,  81 

pruriginosa,  88 

simple,  81 
Vulvo-vaginitis  in  children,  119 

Wolffian   body.     See  Mesonephros, 

51 

duct.     See  Mesonephric  Duct,  51 


PUBLISHED    BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

*American  Text-Book  of  Applied  Thera- 

peiuics 7 

*Americaii  Text-Book  of  Diseases  of  Chil- 
dren      5 

*Ameiican 'I'ext- Book  of  Gynecology  .  .  .  6 
American  Text-Book  of  Nursing  ....  7 
■''American  Text-Book  of  Obstetrics  ...  7 
*American  Text-Book  of  Physiology  ...  7 
♦American  Text-Book  of  Practice  ....  4 
♦American  Text-Book  of  Surgery    ....    3 

Ashton's  Obstetrics        22 

Atlas  of  Skin  Diseases 10 

Ball's  Bacteriology 22 

Bastin's   Laboratory  Exercises  in  Botany  .  16 

Beck's  Surgical  Asepsis 20 

Boisliniere's    Obstetric    Accidents,    Emer- 
gencies, and  Operations 23 

Brockway's  Physics 22 

Burr's  Nervous  Diseases 20 

Cerna's  Notes  on  the  Newer  Remedies  .    .  12 
Chapman's     Medical    Jurisprudence     and 

To.\icology 20 

Cohen  and   Eshiier's  Diagnosis 22 

Cr.igin's  Gynaecology 22 

DaCosta's  IManual  of  Surgery   ......  20 

*De  Schweinitz's  Diseases  of  the  Eye  .    .  10 
Diet-List  and  Sick-Room   Dietary  .    .    .    .  iS 

Dorland's  Obstetrics 20 

Frothingham's    Guide    to    Bacteriological 

Laboratory 16 

Garrigues'  Diseases  of  Women 14 

Gleason's  Diseases  of  the  Ear 22 

Griffin's  Materia  Medica  and  Therapeutics  20 

Griffith's  Care  of  the  Baby 18 

♦Gross's  Autobiography 8 

Hare's  Physiology 22 

Hampton's    Nursing  :    its    Principles   and 

Practice 17 

Haynes'  Manual  of  Anatomy 20 

Hyde's  Syphilis  and  Venereal  Diseases  .    .  20 
Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 22 

Jewett's  Outlines  of  Obstetrics 15 

♦Keating's     Pronouncing     Dictionary    of 

Medicine 8 

Keating's    How  to   Examine  for  Life   In- 
surance     17 


Keen's  Operation  Blanks 16 

Kyle's  Diseases  of  Nose  and  Throat   ...  20 

Laine's  Temperature  Charts 12 

Lockwood's  Practice  of  Medicine    ....  20 

Long's  Syllabus  of  Gynecology 14 

McFarland's  Pathogenic  Bacteria   ....  16 

Martin's  Surgery 22 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 22 

Morris'  Materia  Medica  and  Therapeutics  22 

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Morten's  Nurses'  Dictionary i8 

Nancrede's  Anatomy  and  Manual  of  Dis- 
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Saunders'   American  Year-Book  of  Medi- 
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Sayre's  Practice  of  Pharmacy 22 

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Hygiene 22 

♦Senn's  Pathology  and  Treatment  of  Tu- 
mors     9 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  15 
Shaw's  Nervous  Diseases  and  Insanity  .    .  22 

Starr's  Diet  Lists  for  Children 18 

Stelwagon's  Diseases  of  the  Skin 22 

Stengel's  Manual  of  Pathology 20 

Stevens'  INIateria  Medica  and  Therapeutics  12 

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Stewart    and    Lawrance's    Medical    Elec- 
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♦Warren's  Surgical  Pathology 9 

Wolff's  Chemistry 22 

Wolff's   Ivxamination  of  Urine 22 


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CONTIMBIITORS : 


Dr.  Charles  H.  Burnett,  Pliiladelp'nia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  N.  Y. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  ("hicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thomson,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  verj' 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
Londo7i  Lancet. 


fV.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Eiliied 
by  William  Pkppek,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  alxjut 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume :  Cloth,  SS-OO  net;  Sheep  or  Half-Morocco,  56.00  net. 

VOI.UME   I.   tOXTAIXS: 


Hygiene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Mcningiiis,  and  Relapsing). — Scarla- 
tina, Measles,  kothcln.  Variola,  Varioloid, 
Vjccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
loiis.  Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  V'ellow  Fever. — 
Nervous,  Muscidar,  and  Mental  Diseases  etc. 


VOLUME   II.  CONTAINS: 

Urine  (Chemistry  and  Microscopy). — Kid-  \  —Peritoneum,  Liver, and  Pancreas. — Diathet- 
ney  and  Lungs. — Air-passages  (Larynx  and  '  ic  Diseases  (Rheumatism,  Rheumatoid  Ar- 
Bronchi) and  Pleura. — Pharynx.  CEsophagus,  thritis.  Gout.  Liiha;mia,  and  Diabetes.)— 
Stomach  and  Intestines  (including  Intestinal  Blood  and  Spleen. — Inflammation,  Embolism, 
Parasites),  Heart,  Aorta,  Arteries  and  Veins.  |  Thrombosis,  Fever,  and  Bacteriology. 

The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  forrauk^.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  nre  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBl'TORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  II.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  C.ilnian  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whiitaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  wc  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  thb  rkst  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be."— AVtk  i'ork  Medkal  Journal. 

"A  library  tipon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  journal. 


CATALOGUE    OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1190  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices  :  Cloth,  ^7.00 ;  Sheep  or  Half-Morocco,  3S.00. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  podiatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

One  decided  innovation  is  the  large  number  of  authors,  nearly  every  article 
being  contributed  by  a  specialist  in  the  line  on  which  he  writes.  This,  while 
entailing  considerable  labor  upon  the  editors,  has  resulted  in  the  publication  of 

a  work  THOROUGHLY    NEW    AND    ABREAST    OF   THE   TIMES. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin  ;  while  the  introductory  chapters  cover  fully  the 
important  subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of 
Food.  Tracheotomy,  Intubation,  Circumcision,  and  such  minor  surgical  pro- 
cedures coming  within  the  province  of  the  medical  practitioner  are  carefully 
considered. 

CONTRIBUTORS : 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
Landon  Carter  Gray,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardawav.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik>  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  RL  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K.  Mills,  Philadelphia. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  -A..  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  M.  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia. 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
M.  Allen  .Starr,  New  York. 
J.  Madison  Taylor,  Philadelphia. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Midi 
Thompson  S.  Westcott,  Philadelphia. 
Henry  R.  Wharton,  Philadclpliia. 
J.  William  White.  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


W.   B.   SAUNDERS* 


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AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  Baluy,  M.  D.  Forming  a  handsome  royal-octavo  volume, 
with  360  illustrations  in  text  and  37  colored  and  half-tone  plates.  Prices : 
Cloth,  $6.00  net;  Sheep  or  Hall-Morocco,  S7.00  net. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  tlie  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  woik,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

The  work  is  well  illustrated  throughout  with  wood-cuts,  half-tone  and 
colored  plates,  mostly  selected  from  the  authors'  private  collections. 


CONTRIBrTORS : 


Dr.  Henry  T.  Byfurd. 
John  M.  Baldy. 
Edwin  Cragin. 
I.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yottrnal. 

"A  valuable   addition   to  the  literature  of  Gynecology.      The  writers   are   progressive, 
aggressive,  and  earnest  in  their  convictions." — Medical  News,  Philadelphia. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  0/  Surgery. 

'I  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  0/  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


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AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  By  American 
Teachers.  Richard  C.  Norris,  A.  M.,  M.  D.,  Editor;  Robert  L. 
Dickinson,  M.  D.,  Art  Editor.  Contributors:  James  H.  Etheridge, 
M.  D.;  Chauncey  D.  Pahner,  M.D.;  Howard  A.  Kelly,  M.D.;  Charles 
Jewett,  M.  D. ;  Henry  J.  Gamgues,  M.  D. ;  Barton  Cooke  Hirst,  M.  D. ; 
Theophilus  Parvin,  M.  D. ;  George  A.  Piersol,  M.  D. ;  Edward  P.  Davis, 
M.  D. ;  Charles  Warrington  Earle,  M.  D. ;  Robert  L.  Dickinson,  M.  D. ; 
Edward  Reynolds,  M.  D. ;  Henry  Schwarz,  M.  D. ;  and  James  C.  Cam- 
eron, M.  D.  In  one  very  handsome  imperial-octavo  volume,  with  nearly  900 
illustrations,  including  full-page  plates,  and  uniform  with  "  An  American 
Text-Book  of  Gynecology."  Prices:  Cloth,  ^7.00  net;  Sheep  or  Half- 
Morocco,  ^8.00  net. 

Such  an  array  of  well-known  teachers  is  a  sufficient  guarantee  of  the  high 
character  of  the  work,  and  it  gives  the  assurance  that  this  work  will  have  the 
same  measure  of  success  awarded  it  as  attended  the  recent  publication  of  its 
companion  volume,  "  An  American  Text-Book  of  Gynecology." 

While  the  writers  have  each  been  assigned  special  themes  for  discussion,  the 
correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures  logical  connec- 
tion in  treatment,  the  deductions  of  which  thoroughly  represent  the  latest 
advances  in  the  science  and  elucidate  the  best  modem  methods  of  procedure. 

The  illustrations  have  received  the  most  minute  attention ;  the  cuts  interspersed 
throughout  the  text,  and  the  full-page  plates,  reflect  the  highest  attainments  of 
the  artist  and  engi-aver,  and  appeal  at  once  to  the  eye  as  well  as  to  the  mind  of 
the  student  and  practitioner. 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 

By  American  Teachers.  Edited  by  J.  C.  Wilson,  M.  D.,  Professor  of 
the  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Jefferson  Medical 
College,  Philadelphia.     (Nearly  Ready.) 


AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  By  American 
Teachers.  Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor 
of  Physiology,  Johns  Hopkins  University.  (In  preparation  for  early  pub- 
lication.) 

AN  AMERICAN    TEXT-BOOK    OF    NURSING.      By   American 

Teachers.     (In  preparation.) 


kV.   B.   SAUNDERS' 


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A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Pxdiatric  Society ;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors;  Editor  "  Cyclo- 
pjedia  of  the  Diseases  of  Children,"  etc.;  and  Henry  Hamilton,  author 
of  "A  New  Translation  of  Virgil's  /Eneid  into  English  Rhyme;"  co- 
author of  "  Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collalwration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices  :  Cloth,  $5.00  net ; 
Sheep,  $6.00  net ;  Half-Russia,  ^6.50  net,  with  Denison's  Patent  Ready- 
Reference  Index  ;  without  patent  index,  Cloth,  $4.00  net ;  Sheep,  $5.00  net. 
PROFESSIONAI.  OPINIONS. 
"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henky  M.  Lyman,  M.  D.. 
Professor  of  Principles  and  Practice  0/  Medicine,  Rush  Medical  College,  Chicago,  III. 
"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LiNDSLBY,  M.  D., 

Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University: 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn, 
"  I  will  point  out  to  my  classes  the  many  good  features  of  this  book  as  compared  with 
others,  which  will,  I  am  sure,  make  it  very  popular  with  students." 

John  Cronyn,  M.  D.,  LL.D., 
Professor  of  Principles  and  Practice  of  Medicine  and  Clinical  Medicine ; 

President  of  the  Faculty,  Medical  Dept.  Niagara  University ,  Buffalo,  N.  V. 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 

fe.ssor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes, 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.     Price,  $5.00  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
-within  three  months  of  his  death,  contains  a   full   and   accurate  histor)-  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  di.stingnished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  .\nierica  and  in 
Europe ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


CATALOGUE    OF  MEDICAL    WORKS. 


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SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  J.  Col- 
lins Warren,  M.  D.,  LL.D.,  Professor  of  Surgeiy,  Harvard  Medical 
School,  etc.  One  handsome  octavo  volume  of  832  pages,  with  136  illus- 
trations, 33  of  which  are  chromo-lithographs,  and  all  of  which  were  drawn 
from  original  specimens.   Prices  :  Cloth,  ^6.00  net ;  Half-Morocco,  ^7.00  net. 

Covering  as  it  does  the  entire  field  of  Surgical  Pathology  and  Surgical  Thera- 
peutics by  an  acknowledged  authority,  the  publisher  is  confident  that  the  work 
will  rank  as  a  standard  authority  on  the  subject  of  which  it  treats.  Particular 
attention  has  been  paid  to  Bacteriology  and  Surgical  Bacteria  from  the  stand- 
point of  recent  investigations.  The  chromo-lithographic  plates  in  their  fidelity  to 
nature  and  in  scientific  accuracy  are  incomparable. 

PATHOLOGY  AND  SURGICAL  TREATMENT  OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College ;  Professor  of  Surgeiy,  Chicago 
Polyclinic;  Attending  Surgeon  to  Presbyterian  Hospital;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Prices:  Cloth,  $6.00  net; 
Half-Morocco,  ^7.00  net. 

This  work  epitomizes  the  results  of  many  years  of  personal  observation  and 
successful  experience  of  its  author^  whose  professional  eminence  guarantees  the 
authoritative  character  of  the  subject-matter.  The  illustrations  are  profuse  and 
unusually  fine,  including  more  than  loo  original  photographic  reproductions  of 
the  microscopic  appearances  of  a  great  variety  of  morbid  conditions. 

MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Second  Enlarged  German  Edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Third  and  Revised  Edition.  In 
one  handsome  royal-octavo  volume  of  700  pages,  178  fine  wood-cuts  in 
text,  many  of  which  are  in  colors.  Prices  :  Cloth,  ^4.00  net;  Sheep,  ^5.00 
net;  Half  Russia,  $5.50  net. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  aiid  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as 
a  factor  in  the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and 
Italian.  The  issue  of  a  tliird  American  edition  within  two  years  indicates  the 
favor  with  which  it  has  been  received  by  the  profession. 


10  PV.  B.   SAUNDERS' 


For  Sale  by  Subscription. 

DISEASES  OF  THE  EYE.  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  DE  ScHWElNlTZ,  M.  D.,  Professor  of  Diseases  of  tlie  Eye,  Phila- 
delphia Polyclinic;  Professor  of  Clinical  Ophthalmology,  Jefferson  Medical 
College,  l'iiiladelj>liia,  etc.  A  handsome  royal-oclavo  volume  of  nearly  700 
pages,  with  256  fine  illustrations,  many  of  whicli  are  original,  and  2  chromo- 
liihographic  plates.  Prices:  Cloth,  $4.00  net;  Sheep,  $5.00  net;  Half- 
Russia,  $5.50  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  object  of  this  work  is  to  present  to  the  student  and  practitioner  who  is 
beginning  work  in  the  fields  of  ophthalmology  a  plain  descri|)tiijn  of  the  optical 
defects  and  diseases  of  the  eye.  To  this  end  special  attention  has  lieen  paid 
to  the  clinical  side  of  the  question;  and  the  method  of  examination,  the  symp- 
tomatology leading  to  a  diagnosis,  and  the  treatment  of  the  various  ocular  defects 
have  been  brought  into  special  prominence.  The  general  plan  of  the  took  is 
eminently  practical.  Attention  is  called  to  the  large  number  of  illustrations 
(nearly  one-third  of  which  are  new),  which  will  materially  facilitate  the  thorough 
understanding  of  the  subject. 

"At  once  comprehensive  and  thoroughly  up  to  date." — Hospital  Gazette  (London). 

PROFESSIONAL.  OPINIONS. 

"Contains  in  concise  and  reliable  form  the  accepted  views  of  Ophthalmic  Science." 

William  Thomson,  M.  D., 
Professor  0/  Ophthahnology ,  ycfferson  RIedical  College,  Philadtlphia ,  Pa. 

"  A  very  reliable  guide  to  the'study  of  eye  diseases,  presenting  the  latest  facts  and  newest 
i'l'^a.s."  Swan  M.  Burnett,  M.  D., 

Professor  of  Ophthahnology  and  Otology,  Medical  Department  Univ.  of  Georgetcnun, 

Washington,  D.  C. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  V.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromcs  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  $3.00  per  Part.     Parts  i  to  3  now  ready. 

"The  plates  are  beautifully  executed." — Jonathan  Hutchinson,  M.  D.  (London 
Hospital). 

"  The  plates  in  this  Atlas  are  remarkably  accurate  and  artistic  reproductions  of  typical 
examples  of  skin  disease.  The  work  will  be  of  great  value  to  the  practitioner  and  student." 
— William  Andkuson,  ^L  D.  (St.  Thomas  Hospital). 


CATALOGUE   OF  MEDICAL    WORKS.  11 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Mints  on  Dissection  "  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ;^2.oo  net. 

Neither  pains  nor  expense  has  l)een  spared  to  make  this  work  the  most  e.x- 
haustive  yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in 
their  work  in  the  dissecting-room." — Jourttal  of  Ainericati  Medical  Association. 

"  Should  be  in  the  hands  of  every  medical  student." — Cleveland  Medical  Gazette. 

"  A  concise  and  judicious  work." — Buffalo  Medical  and  Surgical  Journal. 


A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College 
of  Philadelphia.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations,  and  includes  the  following  sections :  General 
Diseases,  Diseases  of  the  Digestive  Organs,  Diseases  of  the  Respiratory 
System,  Diseases  of  the  Circulatory  System,  Diseases  of  the  Nervous  Sys- 
tem, Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  and  Diseases  of  the 
Skin.  Each  section  is  prefaced  by  a  chapter  on  General  Symptomatology. 
Third  edition.  Post  8vo,  502  pages.  Numerous  illustrations  and  selected 
formulae.     Price,  $2.50. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


12  H^.   B.   SAUNDERS 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  SiEVKNS,  A.  M.,  M.  I>.,  Inslrutlor  of  Physical  J>iaj^no.sis  in  llie 
University  of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.     435  pages.     Price,  Cloth,  J2.25. 

This  wholly  new  volume,  which  is  based  on  the  1890  edition  of  the  Pharma- 
r^/a??rt,  comprehends  the  following  sections:  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases;  the  treatment  being  elucidated  by  more  than  two  hundred  formula;. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." — Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  f.Tithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guXAc."  —  University  Medical  Magazine. 


NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.  Second  edition,  revised  and  enlarged. 
Post-octavo,  253  pages.     Price,  $1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  system.Ttic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE  CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  P'ecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE   OF  MEDICAL    WORKS.  1 3 

SAUNDERS'  POCKET  MEDICAL  LEXICON;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
Keating,  M.  D.,  editor  of  "Cyclopedia  of  Diseases  of  Children,"  etc.; 
author  of  the  "  New  Pronouncing  Dictionaiy  of  Medicine;  and  Henry 
Hamilton,  author  of  "  A  New  Translation  of  Virgil's  yEneid  into  Eng- 
lish Verse;"  co-author  of  a  "  New  Pronouncing  Dictionary  of  Medicine." 
A  new  and  revised  edition.  32mo,  282  pages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  $1.00. 

This  new  and  comprehensive  work  of  reference  is  the  outcome  of  a  demand 
for  a  more  modern  handljook  of  its  class  than  those  at  present  on  the  market, 
which,  dating  as  they  do  from  1855  '^^  1884,  are  of  but  trifling  use  to  the  student 
by  their  not  containing  the  hundreds  of  new  words  now  used  in  current  litera- 
ture, especially  those  relating  to  Electricity  and  Bacteriology. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  definition."— y<?«r«iz/  of  Amer- 
ican Medical  Association. 

"  Brief,  yet  complete  ....  it  contains  the  very  latest  nomenclature  in  even  the  newest 
departments  of  medicine." — Ne^u  York  Medical  Record. 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Third 
edition,  revised  and  greatly  enlarged.  Handsomely  bound  in  morocco, 
with  side  index,  wallet,  and  flap.     Price,  $1.75  net. 

A  concise,  clear,  and  correct  record  of  the  many  hundreds  of  famous  formulse 
which  are  found  scattered  through  the  works  of  the  most  eminent  physicians 
and  surgeons  of  the  world.  The  work  is  helpful  to  the  student  and  practitioner 
alike,  as  through  it  they  become  acquainted  with  numerous  formulae  which  are 
not  found  in  text-books,  but  have  been  collected  from  among  the  rising  genera- 
tion of  the  profession,  college  professors,  and  hospital  physicians  and  surgeons. 

"  This  little  book,  thnt  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given  is  unusually  reliable." — New  York  Medical  Record. 

"  Designed  to  be  of  immense  help  to  the  general  practitioner  in  the  exercise  of  his  daily 
calling." — Bos/an  Medical  and  Surgical  yournal. 


14  IV.   B.   SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.  D., 
Professor  of  01)stetrics  in  the  New  York  Post-Graduale  Medical  School 
and  Ilosijilal;  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  etc.,  New  York  City.  In  one  very  handsome  octavo  volume 
of  about  700  pages,  illustrated  by  numerous  wood-cuts  and  colored  plates. 
Prices  :  Cloth,  $4.00  net;   Sheep,  ^5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fuUv  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  ih&  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

EXCERPT  OF   CONTEXTS. 

Development  of  the  Female  Genitals. — Anatomy  of  the  Female  Pelvic  Organs. — Phys- 
iology.—  Puberty. — Menstruation  and  Ovulation. — Copulation. — Fecundation. — The  Climac- 
teric.— Etiology  in  General. — Examinations  in  General. — Treatment  in  General — Abnormal 
Menstruation  and  Metrorrhagia. — Leucorrhea. — Diseases  of  the  Vulva. — Diseases  of  the 
Perineum. — Diseases  of  the  Vagina. — Diseases  of  the  Uterus. — Diseases  of  the  Fallopian 
Tubes. — Diseases  of  the  Ovaries. — Diseases  of  the  Pelvis. — Sterility. 

The  reception  accorded  to  this  work  has  been  most  flattering.  In  the  short 
period  which  has  elapsed  since  its  issue  it  has  been  adopted  and  recommended 
as  a  text-book  by  more  than  60  of  the  Medical  Schools  and  Universities  of  the 
United  States  and  Canada. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  Torm.  Voimg  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  .a.  Reamv,  M.D.,  LL.D., 
Professor  0/  Clinical  Gynecology ,  Medical  College  of  Ohio:   Gynecologist  to  the  Good 
Samaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  wiio  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  tlie  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
and  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  1$ 

OUTLINES  OF  OBSTETRICS:  A  Syllabus  of  Lectures  Deliv- 
ered at  Long  Island  College  Hospital.  By  Charles  Jewett,  A.  M., 
M.  D.,  Professor  of  Obstetrics  and  Pediatrics  in  the  College,  and  Obstetri- 
cian to  the  Hospital.  Edited  by  Harold  F.  Jewett,  M.  D.  Post  8vo, 
264  pages.     Price,  $2.00. 

This  book  treats  only  of  the  general  facts  and  principles  of  obstetrics :  these 
are  stated  in  concise  terms  and  in  a  systematic  and  natural  order  of  sequence, 
theoretical  discussion  being  as  far  as  possible  avoided ;  the  subject  is  thus 
presented  in  a  form  most  easily  grasped  and  remembered  by  the  student. 
Special  attention  has  been  devoted  to  practical  questions  of  diagnosis  and 
treatment,  and  in  general  particular  prominence  is  given  to  facts  which  the  stu- 
dent most  needs  to  know.  The  condensed  form  of  Statement  and  the  orderly 
arrangement  of  topics  adapt  it  to  the  wants  of  the  busy  practitioner  as  a  means 
of  refreshing  his  knowledge  of  the  subject  and  as  a  handy  manual  for  daily 
reference. 

"  Rarely  has  it  been  our  fortune  to  read  a  work  of  this  nature  where,  from  the  beginning  to 
the  end,  definitions  are  so  exact  and  rules  for  guidance  so  safe." — American  Journal  of 
Obstetrics,  New  York. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsyl- 
vania. Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo. 
Price,  Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant ;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — Neiv  York  Itledical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgeiy  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  $2.00. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors 
to  "  An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  makinc;  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operation.^.  Full 
references  are  also  given  to  all  rei-iuisite  details  of  surgical  anatomy  and  pathology." — British 
Medical  Journal,  London. 


1 6  IV.   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  \V.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used —viz.  general  instru- 
ments, etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's otilice  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — New  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." — Boston  iiledical  and  Surgical  "jfournal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Ed.son  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  52.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flo\vering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  l^een  added. 

TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Specially 
written  for  students  of  medicine.  By  Joseph  McFarlano,  .M.  D.,  Demon- 
strator of  Pathological  Histology,  and  Lecturer  on  Bacteriology,  in  the 
Medical  Department  of  the  University  of  Pennsylvania.  Price,  Cloth, 
$2.50  net. 

A  concise  account  of  the  technical  procedures  necessary  in  the  study  of  Bac- 
teriology.     Finely  illustrated. 

A  GUIDE  TO  THE  BACTERIOLOGICAL  LABORATORY.     By 

Langdon  Frothingham,  M.  D.     Illustrated.     Price,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work. 


CATALOGUE    OF  MEDICAL    WORKS.  IJ 


HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keatim;,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelpliia ;  Vice-President  of  the  American  Poediatric  Society ;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
Svo,  2H  pages,  with  two  large  half-tone  illustrations,  and  a  plate  juepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  te.\t.     Second  edition.     Price,  Cloth,  ^2.00  net. 

Part  I.,  carefully  prepared  from  the  best  works  on  Physical  Diagnosis,  gives  a 
succinct  account  of  the  methods  used  in  making  examinations,  and  a 
description  of  the  normal  condition  and  of  the  earliest  evidences  of  disease. 

Part  IL  contains  the  Instructions  of  twenty-four  Life-Insurance  Companies  to 
their  medical  examiners. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If:  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — TVzi?  il/fifea/ yWrcj,  Philadelphia.  •■     ' 


.NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
AD.A.M3  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital ;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nur.ses,  Chicago,  111.  In  one  very  handsome  121110  volume  of  484 
pages,  profusely  illustrated.     Price,  Cloth,  $2.00  net.  . 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction'  df 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  ISy  E.mily  A.  M.  Sto.ney,  Graduate  of  the  Training-school 
for  Nurses,  Lawi  ence,  Massachusetts ;  Superintendent  of  Training-school 
for  Nurses,  Carney  Hospital,  South  Boston.  i2mo.,  400  pages.  Price, 
Cloth,  $1.75  net. 

•  A  vade  viecum  for  the  private  nurse,  and  an  eflicient  teaching-book  for  train- 
ing-schools. A  valuable  feature  is  the  instructions  for  quickly  ir/iprcniising 
needed  sick-room  appliances. 


1 8  IV.  B.   SAUNDERS^ 


THE  CARE  OF  THE  BABY.  By  J.  I'.  Crozir  Griffith,  M.  D., 
Clinical  Professor  of  J  tiseascs  of  Children,  and  Instructor  in  Clinical 
Medicine,  Medical  Department  University  of  Pennsylvania;  Physician  to 
St.  Agnes',  Howard,  St.  Clements,  and  the  Childrens  Hospitals,  Phila- 
iiel]iliia,  etc.  392  pages,  with  67  illustrations  in  the  text,  and  5  plates. 
i2mo.     Price,  $1.50. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

THE  NURSES  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Detlniiions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  .\ccidents.  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  Compiled 
for  the  use  of  nurses.  By  Ho.nnor  Morten,  author  of  "  How  to  Become 
a  Nurse,"  "Sketches  of  Hospital  Life,"' etc.  i6mo,  140  pages.  Price, 
Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital ;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price.  Cloth,  $1.^0    (.Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Anaemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric-Acid  Diathesis,  Obesity,  and  Tulierculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessarj'  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  n(j  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Lot:is  St.\kr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
])erfrirated  and  neatly  bound  in  flexible  morocco.     Price,  $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Foivnilct 
for  the  preparation  of  diluents  and  foods  are  appended. 


Practical,  Exhaustive,  Authoritative. 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS 

FOR 

Students  and  Practitioners. 


Mr.  Saunders  is  pleased  to  announce  as  now  ready  his  NEW  AID 
SERIES  OF  MANUALS  for  Students  and  Practitioners.  As  pub- 
lisher of  the  Standard  Series  of  Question  Compends,  and  through  intimate 
relations  with  leading  members  of  the  medical  profession,  Mr.  Saunders  has 
been  enabled  to  study  progressively  the  essential  desiderata  in  practical  "  self- 
helps  "  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "  Question  Compends  " 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgery,  each  subject 
being  compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without 
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ordinary  text-books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  netu  series,  therefore,  will  form  an  admirable 
collection  of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in 
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Each  Manual  will  further  be  distinguished  by  the  beauty  of  Uie  tiew  type; 
by  the  quality  of  the  paper  and  printing ;  by  the  copious  use  of  illustrations ; 
by  the  attractive  binding  in  cloth ;  and  by  their  extremely  low  prices. 

19 


SAUNDERS'  NEW  AID  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howaru  Raymonu,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hyf^iene  and  Lecturer  on  Gynecology  in  the  Long 
Lsland  College   Hospital,  etc.      Price,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D„  Demonstrator  of  Surgery,  Jefferson  Medical  College,  Philadelphia, 
etc.     Double  number.     Price,  $2. 50  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION- WRITING. 

IjV  E.  Q.  Thoknton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  31.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  ^ledical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc,     Price,  Si. 50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  3i-2S  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     (Double  number.)     Price,  $2.50  net. 

SYPHILIS    AND     THE    VENEREAL     DISEASES.       By    James 

Nevins  Hyui:,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary' Diseases,  in  Rush  Medical  College,  Chicago.  (Double  number.) 
Price,  S2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  (jf  the  New 
York  Infirmary,  etc.     (Double  number.)     Price,  32.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Asst.  Demonstrator 
of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital.     (Double  number.)     Price,  $2. 50  net. 

VOLUMES  IN  PREPARATION. 

MATERIA  MEDICA  AND  THERAPEUTICS.  By  Henry  A. 
Grii UN,  A.  B.,  M.  D.,  Assistant  Physician  to  the  Roosevelt  Hospital, 
Out- Patient  Department,  New  York  City. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Pro- 
fessor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.  D.,  Chief  Lar)'ngolo- 
gist  to  St.  Agnes'  Hospital,  Philadelphia;  Instructor  in  Clinical  Microscopy 
and  Assistant  Demonstrator  of  Pathology  in  Jefferson  Medical  College. 

PATHOLOGY.     By  Alfred  Stengel,  M.  D.,  Instructor  in  Clinical  Medi- 
cine, Medical  Department,  University  of  Pennsylvania. 
*^*  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-pre- 
pared works  on  the  subjects  of  Anatomy,  Gynecology,  Hygiene,  etc.,  by  prom- 
inent specialists. 


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States  and  Canada. 


THE    REASON    WUY. 

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who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

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pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty-four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessaiy,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO    SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  tieatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

*;::.*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  over 
for  List). 

21 


SAUNDERS'  QUESTION-COMPEND  SERIES. 

Price,  Cloth,  $I.OO  per  copy,  except  when  otherwise  noted. 

1.  ESSENTIALS  OF  PHYSIOLOGY.     3(1  edition.     Illustrated.      Re- 

vised  ami  enlargecl  by  11.  A.  Hare,  M.  D      (Price,  Si.oo  net.) 

2.  ESSENTIALS  OF  SURGERY.     5tli   edition,  witli   an  Appendix  on 

Antiseptic  Surgery.     90  illu.-.trations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF  ANATOMY.     51)1  edition,  with  an  Appendix.     180 

illustrations.      15y  Chari.ks  B.  Nanckede,  M.  1). 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 

INORGANIC.  4th  edition,  revised,  willi  an  Appendi.x.  By  Law- 
rence WoEKK,  -M.  D. 

5.  ESSENTIALS    OF    OBSTETRICS.     3d    edition,    revised    and    en- 

larged.    75  illustrations.     By  W.  Eastkki.v  Ashtu.n,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY. 

6th  thousand.     46  illustrations.     By  C.  E.  Armand  Semi'I.k,  M.  D. 

7.  ESSENTIALS    OF    MATERIA    MEDICA,    THERAPEUTICS, 

AND  PRESCRIPTION-WRITING.  4th  edition.  By  Henry 
Morris,  M.  D. 

8.  9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.     By  Henry 

Morris,  M.  D.  An  Appendix  on  Urine  E.\ami.n.\tion.  Illustrated. 
By  Lawrence  Wolff,  M.  D.  3d  edition,  enlarged  by  some  300  Es- 
sential Formulae,  selected  from  eminent  authorities,  by  W'm.  M.  Powell, 
M.  D.     (Double  number,  price  $2.00.) 

0.  ESSENTIALS  OF  GYN.^COLOGY.     3d   edition,  revised.     With 

62  illustrations.     By  Edwin  B.  Cr.\gin,  M.  D. 

1.  ESSENTIALS  OF  DISEASES   OF  THE  SKIN.     3d  edition,  re- 

vised and  enlarged.  71  letter-piess  cuts  and  15  half-tone  illustrations. 
By  Henry  W.  Stelwagon,  M.  D.     (Price,  31.00  net.) 

2.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND 

VENEREAL  DISEASES.  2d  edition,  revised  and  enlarged.  78 
illustrations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND 

HYGIENE.      130  illustrations.     By  C.  E.  yVRMAND  .Si-mple,  M.  D. 

4.  ESSENTIALS  OF   DISEASES   OF  THE   EYE,   NOSE,  AND 

THROAT.  124  illu.stralions.  2d  edition,  revised.  By  Edward 
Jackson,  M.  D..  and  E.  Baldwin  Gi.easo.n,  M.  D. 

5.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     4th  thousand. 

By  Wii.LLVM  II.  Powell,  M.  D. 

6.  ESSENTIALS     OF     EXAMINATION     OF     URINE.       Colored 

"  Vogel  Scale,"  and  numerous  illustrations.  By  Lawrence  Wolff, 
M.  D.     (Price,  75  cents.) 

7.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis-Cohen,  M.  D.,  and 

A.  A.  EsHNER,  M.  D.     55  illustrations,  some  in  colors.    (Price,  $1.50  net.) 

8.  ESSENTIALS   OF    PRACTICE    OF   PHARMACY.     By   L.   E. 

Sayre.     2d  edition,  revised. 

20.  ESSENTIALS    OF    BACTERIOLOGY.     2d  edition.     81    illustra- 

tions.    By  M.  V.  Ball,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY. 

48  illustralions.      2d  edition,  revised.     By  JoliN  C.  SllAW,  M.  D. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      155  illustrations.     2d 

edition,  revised.     By  Fked  J.  PjKockwav,  M.  I).     (Price,  $1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations. 

By  iJAVii)  I).  Stewart.  M.  I).,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     By  E.  B.  Glea- 

soN,  M.  D.     89  illustrations. 


RECENT   PUBLICATIONS. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.  L),,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Md.  One  handsome  octavo  volume  of  1052 
pages,  fully  illustrated.  Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half-Morocco, 
#7.00  net. 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 

For  the  Use  of  Practitioners  and  Students.  Edited  by  James  C. 
Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College.  One  handsome  octave  volume 
of  1326  pages.  Illustrated.  Prices:  Cloth,  ^7.00  net;  Sheep  or  Half- 
Morocco,  $8.00  net. 

A  TEXT-BOOK  OF  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.  G.,  M.  D., 

Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians  and  Surgeons,  Chicago,  etc.  8vo,  858  pages.  Illustrated. 
Prices  :  Cloth,  ^4.00  net ;  Sheep  or  Half-Morocco,  ;?5.oo  net. 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Clarkson,  M.  B., 
C.  M.,  Edin.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and 
174  beautifully  colored  original  illustrations.  Price,  strongly  bound  in 
Cloth,  $6.00  net. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diag- 
nosis in  the  Rush  Medical  College,  Chicago ;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  Sydney  Rowland, 
B.  A.,  Camb.  A  series  of  collotype  illustrations,  with  descriptive  text, 
illustrating  the  applications  of  the  new  photography  to  Medicine  and  Sur- 
gery.    Price,  per  Part,  $1.00.     Parts  I.  and  II.  now  ready. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  BoiSLiNiERE,  M.  D.,  late  Emeritus  Professor  of  Ob- 
stetrics in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.     Price,  $2.00  net. 

WATER  AND  WATER  SUPPLIES.  By  John  C.  Thresh,  D.  Sc, 
M.   B.,  D.   P.   H.     i2mo,  438  pages,  illustrated.     Handsomely  bound  in 

Cloth,  with  gold  side  and  back  stamps.     Price,  ^2.25  net. 


KOjr  READY,   VOLUME  tOli  18UG. 


AMERICAN  YEAR-BOOK  OF  MEDICINE  and  SURGERY, 

Edited   by  GEORGE  M.  GOULD,  A.  M.,  M.  D. 

Assisted  by  Eminent  American  Specialiots  and  Teachers. 


2  NOTWITHSTANDINT,  the  rapid  multiplication  of  medical  and  surgical  works, 
o  still  these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician,  s^ 
^  inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  well-  ^I 
"^  known  principles  of  medical  science.  Mr.  Saunders  has  long  been  impressed  J 
,2  with  this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  pro-  *" 
>&  fession  at  large,  as  indicated  by  advices  from  his  large  corps  of  canvassers.  ^ 
fe  This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most  ^ 
"eg  practitioners  have  scant  access  to  this  almost  unlimited  source  of  information,  -* 
S  and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many  5 
^  interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his  5 
C  jiractice.  Therefore,  a  work  which  places  before  the  physician  in  convenient  Ji^ 
,^  form  an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon  ^ 
g  The  Value  of  a  Discovery  or  of  a  Method  of  Treatment  «». 
<l>  cannot  but  command  his  highest  appreciation.  It  is  this  critical  and  judicial  5 
.^  function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year- 
's Book  of  Medicine  and  Surgery."'  « 
s*  .  It  is  the  special  puq:)ose  of  the  Editor,  whose  experience  i>eculiarly  qualifies  <«* 
ijj  him  for  the  preparation  of  this  work,  not  only  to  review  the  contril)Utions  to  (jg 
American  journals,  but  also  the  methods  and  discoveries  reported  in  the  leading  § 
fes  medical  journals  of  Euro]ie,  tints  enlarging  the  survey  and  making  the  work  ^ 
S  characteristically  international.  These  reviews  will  not  simply  be  a  series  of 
§  '  undigested  abstra.cts  indiscriminately  rtin  together,  nor  will  they  be  retrospective  » 
2  ■  of  "  hews  "  oiie  or  two  years  old,  but  the  treatment  jireseiited  will  be  synthetic  2|* 
•<  and  dogmatic,  and  will  include  only  what  is  new.  Moreover,  through  expert  • 
^     condensation  by  experienced  writers  these  discu^sinns  will  l)e 

Comprised  in  a  Single  Volume  of  about  1200  Pages. 
The  work  will  be  replete  with  original  and  selected  illustrations  skilfully 
reproduced,  for  the  most  part  in  Mr.  Saunders'  own  studios  established  for  the 
purpose,  thus  ensuring  accuracy  in  delineation,  affording  efficient  aids  to  a  right 
comprehension  of  the  text,  and  adding  to  the  attractiveness  of  the  volume. 
Prices:  Cloth,  $6.50  net;   Half  Morocco.  , 57- 5°  »*''• 

W.  B.   SAUNDERS,   Publisher, 

925  Walnut  Street,  Philadelphia. 


JUST   ISSUED. 

PENROSE'S  DISEASES  OF  WOMEN. 

A  Text"Book  of  Diseases  of  Women.     l?y  Cmari.f.s  R.  Penrosf,  M.  P.,  I'n.  D., 

I'l-dlbssor  til'  (JyiU'colony,  Uiiivt-rsity  of  rulinsylvania;  SurKeoii  U>  the  (lyiicccan 
lliispitiil,  riiiliiduliihiii."  0(ttav()  Vdluiiie  of  52'J  paKes,  liaiulsoiiiuly  illustrated. 
I'ricf,  So.riO  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  By  Frank  B.  Mai, lory,  A.M.,  M.  D.,  Asst.  Professor 
of  I'iilholoKy,  Hiirviu'd  Medical  School;  and  James  H.  WRKiirr,  A.  M.,  M.I).,  In- 
stnictoi-  in  "I'atholouy,  Harvard  Medical  School.    Octavo  volume  of  390  i)ages, 

liandsoiucly  illustrated.     Price, 

SENN'S  GENITOURINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  iVlale  and  Female.  By  NtfiiOLAS 
Sknn,  M.  1).,  Ph.  J).,  LL.I).,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo  volume  of  320 
pages.    Illustrated.    Price, 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Asst.  Surgeon  to  Middle- 
sex Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ;  and  Arthur  K.  Giles, 
M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S.  Edin.,  Asst.  Surgeon  to  Chelsea  Hospital,  London. 
436  pages,  handsomely  illustrated.    Price,  $2.50  net. 


IN  PREPARATION. 

ANDERS'  PRACTICE  OF  MEDICINE. 

A  Text=Book  of  the  Practice  of  Medicine.    By  James  M.  Anders,  M.  D.,  Ph.  D., 

LL.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Medico- 
Chirurgical  College,  Philadelphia.    In  press. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  IMArDGNALD,  Jf.  D.,  Professor  of 
the  Practice  of  Surgery  and  of  Clinical  Surgery,  Minneapolis  College  of  Physi- 
cians and  Surgeons.    In  press. 

AN  AMERICAN  TEXT  BOOK  OF  QENITO=URINARY  AND  SKIN 
DISEASES. 

Edited  by  L.  Bolton  Bangs,  M.  D.,  Late  Professor  of  Genito-Uri nary  and  Venereal 
Diseases,  New  York  P(jst-Graduate  Medical  School  and  Hosiiital,  and  William 
A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical  College. 

AN    AMERICAN    TEXT=BOOK   OF    DISEASES   OF  THE    EYE, 
EAR,   NOSE,    AND   THROAT. 

Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  and  B.  Alexander  Randall,  M.  D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor  of  Obstet- 
rics, University  of  Pennsylvania. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Professor  of 
()rthoi)edics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of  Minnesota, 
College  of  Medicine  and  Surgery. 

HEISLER'S  EMBRYOLOGY. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Prosector  to  tlic  Pro- 
fessor of  .\natoiiiy.  Medical  Department,  University  of  Pennsylvania. 


jvon  jiJCAJH,  ronrMES  FOR  isua  am>  isut. 


AMERICAN  YEAR-BOOK  OF  MEDICINE  and  SURGERY. 

Edited   by  GEORGE  M.  GOULD,  A.  M.,  M.  D. 

Assisted  by  Eminent  American  Specialiots  and  Teachers. 


NoTWiTHSTANDiNC  the  rapid  multiplication  of  medical  and  surgical  works, 

still  these  publications  fail  to  meet  fully  tlie  requirements  of  the  getttral physician,  j' 

inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-bouks  of  well-  "J- 

known  principles  of  medical  science.     Mr.  Saunders  has  long  been  impressed  '^ 

with  this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  pro-  '^ 

fession  at  large,  as  indicated  by  advices  from  his  large  coqjs  of  canvassere.  5 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most  Si 

practitioners  have  scant  access  to  this  almost  unlimited  source  of  information,  n, 

and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many  ^ 

interesting  cases  whose    study  would  doubtless  be  of  inestimable  value  in  his  :: 

practice.     Therefore,  a  work  which  places  before  the  physician  in  convenient  tu 

form  an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon  S 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment  2. 

cannot  but  command  his  highest  appreciation.     It  is  this  critical  and  judicial  ^ 

function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year-  "^ 

Book  of  Medicine  and  Surgery."  55^ 

It  is  the  special  purpose  of  the  Editor,  whose  experience  peculiarly  qualifies  ?! 

him  for  the  preparation  of  this  work,  not  only  to  review  the  contributions  to  ^C 

American  journals,  but  also  the  methods  and  discoveries  reported  in  the  leading  § 

medical  journals  of  Europe,  thus  enlarging  the  survey  and  making  the  work  ^ 

characteristically  international.     These  reviews  will  not  simply  be  a  series  of  "* 

undigested  abstracts  indiscriminately  run  together,  nor  will  they  be  retrospective  * 

of  "  news  "  one  or  two  years  old,  but  the  treatment  presented  will  be  synthetic  ^ 

and  dogmatic,  and  will  include  only  what  is  new.     Moreover,  through  expert  • 
condensation  by  experienced  writers  these  discussions  will  be 

Comprised  in  a  Single  Volume  of  about  1200  Pages. 
The  work  will  be  replete  with  original  and  selected  illustrations  skilfully 
reproduced,  for  the  most  part  in  Mr.  Saunders'  own  studios  established  for  the 
purpose,  thus  ensuring  accuracy  in  delineation,  affording  efiicient  aids  to  a  right 
comprehension  of  the  text,  and  adding  to  the  attractiveness  of  the  volume. 
Prices:  Cloth,  $6.50  net ;   Half  Morocco,  J?7. 50  net. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  Street,  Philadelphia. 


DUE  DATE 

1 

1 

1 

Printed 
in  USA 

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fe^^t  XotH  tjrt 


COLUMBIA  UN1VERSITY_^^ 

0027094936 


